Volume 44 Number 4

Selected abstracts from the 24th Biennial WCET® Congress in Glasgow, UK

DOI 10.33235/wcet.44.4.39-47

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Abstract

Delegates at the WCET® Congress, in Glasgow, UK in September, were treated to a very successful scientific programme with diverse, stimulating and high-quality content.

For the benefit of the many members who were unable to attend, here is a sample of what was presented by speakers from around the world.

Managing low anterior resection syndrome

Jennie Burch, RN, BSc, MSc
Head of Gastrointestinal Nurse Education, St Mark’s Hospital, London, UK

Claire Taylor, RGN, PhD
Chief Nursing Officer, Macmillan, UK

Ana Wilson, MD
Consultant Gastroenterologist, St Mark’s Hospital, London, UK

Christine Norton, RGN, PhD
Professor of Nursing, King’s College London, UK

Aims/Objectives The presentation aim is to describe nursing management of boel symptoms occurring after rectal cancer treatment. The objectives are to improve nurses’ knowledge and confidence when caring for this patient group.

Purpose & Background It is known, worldwide each year an estimated million people are diagnosed with rectal cancer (Emmertsen & Laurberg, 2013). Rectal cancer treatment is commonly surgery, chemotherapy and radiotherapy which can potentially result in consequences such as bowel dysfunction, collectively termed low anterior resection syndrome or LARS (Keane et al. 2020). The purpose of this presentation will be to increase knowledge about managing LARS after rectal cancer surgery.

Methods A PhD was undertaken using a multi-phase, mixed-method design to investigate LARS management. A systematic review thematically summarised how rectal cancer treatment consequences affect quality of life. A scoping review charted treatments available to manage LARS. Interviews thematically described what patients need to manage LARS. Focus groups with both patients and clinicians thematically described how this might be achieved.

Results Results reveal quality of life can be negatively affected by LARS, particularly when people could not function in their chosen roles (Burch et al, 2021a). Multiple LARS management options exist but empirical data are limited (Burch et al, 2021b). Patients need knowledgeable clinicians to enquire about and revisit symptoms; providing information on management strategies and signposting to other relevant information (Burch et al, 2023a). Clinicians can help set expectations to enable realistic goal planning (Burch et al, 2023b). Nurse-led supported LARS management can improve bowel symptoms in conjunction with supplementary information.

Conclusion/Outcome In conclusion, a greater knowledge about LARS should increase nurses’ confidence to assist patients with rectal cancer to manage their bowel symptoms after rectal cancer treatment. More research is needed to understand how best to provide nurse-led LARS interventions.

Keywords LARS, low anterior resection syndrome, rectal cancer, nurse, survivorship

References

Burch J., Taylor C., Wilson A., Norton C. (2021a) Symptoms affecting quality of life after sphincter-saving rectal cancer surgery: a systematic review. European Journal of Oncology Nursing, 52.

Burch J., Swatton A., Taylor C., Wilson A., Norton C. (2021b) Managing bowel symptoms after sphincter-saving rectal cancer surgery: a scoping review. Journal of Pain and Symptom Management 62(6), 1295-1307.

Burch J., Wright J., Taylor C., Wilson A., Norton C. (2023a) “He’s a surgeon, like I’m not going to waste his time”: interviews to determine healthcare needs for patients with low anterior resection syndrome (LARS) after rectal cancer surgery. Colorectal Disease 25, 880-887.

Burch J., Taylor C., Wilson A., Norton C. (2023b) “You’re just on your own”: Exploring bowel symptom management needs after rectal cancer surgery through patient and clinician focus groups. European Journal Oncology Nursing. https://doi.org/10.1016/j.ejon.2023.102406.

Emmertsen K.J., Laurberg S. (2013) Impact of bowel dysfunction on quality of life after sphincter-saving resection for rectal cancer. British Journal of Surgery 100(10), 1377-1387.

Keane C., Fearnhead N.S., Bordeianou L.G., Christensen P., Basany E.E., Laurberg S., Mellgren A., Messick C., Orangio G.R., Verjee A., Wing K., Bissett I. (2020) International consensus definition of low anterior resection syndrome. Diseases of the Colon & Rectum 63(3), 274-284.

 

All My Life I have to Adapt With My Stoma: A Phenomenological Study

Ria Andjarwati, MD, ONS, ETN,
Head Nurse, Wound and Stoma Consultant, Oncology Nurse Specialist, National Cancer Center “dharmais” Hospital, Indonesia

Yati Afiyanti, Prof. PhD. MN
Honarary Lecture in Nursing Faculty University of Indonesia, University of Indonesia, Indonesia

Aims/Objectives  The purpose of this study was to describe the experiences of cancer patients who had a stoma in the first year. A qualitative descriptive study was conducted.

Purpose & Background Cancer patients who undergo stoma surgery experience a major life change. Many problems arise both physically, psychologically, sexually and spiritually, especially in the first year. Delayed discharge planning in out-of-hospital settings, often happens to new ostomates, because of poor pre-operative education and information. By exploring patients’ experiences thoughout the difficult time with stoma surgery, health care providers can understand and empower the patients with the right care.

Methods Eleven participants were invited for semi-structured in-depth interviews. Data were analysed using thematic analysis.

Results Two themes were identified: 1) Complaints experienced while undergoing therapy; 2). Adaptation to life after stoma. Ostomates facing a major life changes due to adapting to life with the stoma. Many aspects in ostomates’ live need to be adjusted, Feelings of rejection and denial rise up in approximately the first month after stoma surgery. Adjustment followed by adaptation finally acknowledged by the ostomate entering six month above.

Conclusion/Outcome  This study provides nurses and others with insight in to the experiences of Indonesian ostomates about their adaptation processes physically, psychologically, socially, spiritually and sexually, and their plans for their future lives with stoma. It is very useful for patients with colorectal cancer or other cancers who undergo a life with a stoma attached.

Keywords cancer patients, experience, ostomate, postoperative, stoma

References

  1. Alenezi A, McGrath I, Kimpton A, Livesay K. Quality of life among ostomy patients: A narrative literature review. J Clin Nurs. 2021;30(21-22):3111-3123. doi:10.1111/jocn.15840
  2. Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, Znaor A, Soerjomataram I BF. International Agency for Research on Cancer 2020. Glob Cancer Obs Cancer Today. 2020;419:1-2.
  3. Kugler CM, Breuing J, Rombey T, et al. The effect of preoperative stoma site marking on risk of stoma-related complications in patients with intestinal ostomy—protocol of a systematic review and meta-analysis. Syst Rev. 2021;10(1):1-8. doi:10.1186/s13643-021-01684-8
  4. Summers MC. The Effect of Ostomate-to-Ostomate Support on Psychosocial Adaptation to Stoma. Dr Nurs Pract Capstone Proj. 2018;28.
  5. Burch J. Post-discharge care for patients following stoma formation: what the nurse needs to know. Nurs Stand. 2017;31(51):41-45. doi:10.7748/ns.2017.e10198
  6. Capilla-Díaz C, Bonill-de las Nieves C, Hernández-Zambrano SM, et al. Living With an Intestinal Stoma: A Qualitative Systematic Review. Qual Health Res. 2019;29(9):1255-1265. doi:10.1177/1049732318820933
  7. Vonk-Klaassen SM, de Vocht HM, den Ouden MEM, Eddes EH, Schuurmans MJ. Ostomy-related problems and their impact on quality of life of colorectal cancer ostomates: a systematic review. Qual Life Res. 2016;25(1):125-133. doi:10.1007/s11136-015-1050-3
  8. Hahne J, Liang T, Khoshnood K, Wang X, Li X. Breaking bad news about cancer in China: Concerns and conflicts faced by doctors deciding whether to inform patients. Patient Educ Couns. 2020;103(2):286-291. doi:10.1016/j.pec.2019.08.022
  9. de Almeida Silva K, Duarte AX, Cruz AR, de Araújo LB, das Graças Pena G. Time after ostomy surgery and type of treatment are associated with quality of life changes in colorectal cancer patients with colostomy. PLoS One. 2020;15(12):1-17. doi:10.1371/JOURNAL.PONE.0239201
  10. Dibley L, Czuber-Dochan W, Wade T, et al. Patient Decision-Making about Emergency and Planned Stoma Surgery for IBD: A Qualitative Exploration of Patient and Clinician Perspectives. Inflamm Bowel Dis. 2018;24(2):235-246. doi:10.1093/ibd/izx043
  11. Cross AJ, Wooldrage K, Robbins EC, et al. Whole-colon investigation vs. flexible sigmoidoscopy for suspected colorectal cancer based on presenting symptoms and signs: a multicentre cohort study. Br J Cancer. 2019;120(2):154-164. doi:10.1038/s41416-018-0335-z
  12. Jin Y, Zhang J, Zheng MC, Bu XQ, Zhang JE. Psychosocial behaviour reactions, psychosocial needs, anxiety and depression among patients with rectal cancer before and after colostomy surgery: A longitudinal study. J Clin Nurs. 2019;28(19-20):3547-3555. doi:10.1111/jocn.14946
  13. Jayarajah U, Samarasekera DN. Psychological adaptation to alteration of body image among stoma patients: A descriptive study. Indian J Psychol Med. 2017;39(1):63-68. doi:10.4103/0253-7176.198944
  14. Tiranda Y, Siripul P, Sangchart B, Septiwi C. Perspectives of adult survivors of colorectal cancer with an ostomy on their needs: Synthesis of qualitative research studies. Cent Eur J Nurs Midwifery. 2019;10(4):1155-1166. doi:10.15452/CEJNM.2019.10.0027
  15. Rafiei H, Hosseinzadeh K, Hoseinabadi-Farahani MJ, et al. The relationship between psychological health and spiritual wellbeing in Iranian stoma patients. Gastrointest Nurs. 2019;17:S18-S22. doi:10.12968/gasn.2019.17.Sup5.S18
  16. Rafiei H, Hoseinabadi-Farahani MJ, Aghaei S, Hosseinzadeh K, Naseh L, Heidari M. The prevalence of psychological problems among ostomy patients: A cross-sectional study from Iran. Gastrointest Nurs. 2017;15(2):39-44. doi:10.12968/gasn.2017.15.2.39
  17. Choudhary M, Kaur H. Experiences of living with intestinal ostomy: A qualitative meta-synthesis. Indian J Palliat Care. 2020;26(4):421-427. doi:10.4103/IJPC.IJPC_21_20
  18. ingan MJ, Kump K. Getting Ready for Ostomy Certification. J Wound, Ostomy Cont Nurs. 2022;49(3):290-293. doi:10.1097/won.0000000000000872
  19. Kirkland-Kyhn H, Martin S, Zaratkiewicz S, Whitmore M, Young HM. Ostomy Care at Home educating family caregivers on stoma management and potencial complications. Am J Nurs. 2018;118(4):63-68. https://nursing.ceconnection.com/ovidfiles/00000446-201804000-00035.pdf;jsessionid=E5B7110C68566021C914937447205896
  20. Marinez AC, Bock D, Carlsson E, et al. Stoma-related complications: a report from the Stoma-Const randomized controlled trial. Color Dis. 2021;23(5):1091-1101. doi:10.1111/codi.15494
  21. Bulkley JE, McMullen CK, Grant M, Wendel C, Hornbrook MC, Krouse RS. Ongoing ostomy self-care challenges of long-term rectal cancer survivors. Support Care Cancer. 2018;26(11):3933-3939. doi:10.1007/s00520-018-4268-0
  22. Stelton S. CE: Stoma and Peristomal Skin Care: A Clinical Review. Am J Nurs. 2019;119(6):38-45. doi:10.1097/01.NAJ.0000559781.86311.64
  23. Correa Marinez A, Bock D, Carlsson E, et al. Stoma-related complications: a report from the Stoma-Const randomized controlled trial. Color Dis. 2021;23(5):1091-1101. doi:10.1111/codi.15494
  24. Rowe KM, Schiller LR. Ileostomy diarrhea: Pathophysiology and management. Baylor Univ Med Cent Proc. 2020;33(2):218-226. doi:10.1080/08998280.2020.1712926
  25. Alenezi A, McGrath I, Kimpton A, Livesay karen. Quality of life among ostomy patients: A narrative literature review. J Clin Nurs. 2021;30(21-22):3111-3123. doi:10.1111/JOCN.15840
  26. Nam KH, Kim HY, Kim JH, Kang KN, Na SY, Han BH. Effects of social support and self-efficacy on the psychosocial adjustment of Korean ostomy patients. Int Wound J. 2019;16(October 2018):13-20. doi:10.1111/iwj.13038
  27. García-Rodríguez MT, Barreiro-Trillo A, Seijo-Bestilleiro R, González-Martin C. Sexual dysfunction in ostomized patients: A systematized review. Healthc. 2021;9(5):1-11. doi:10.3390/healthcare9050520
  28. Zhang Y, Xian H, Yang Y, Zhang X, Wang X. Relationship between psychosocial adaptation and health-related quality of life of patients with stoma: A descriptive, cross-sectional study. J Clin Nurs. 2019;28(15-16):2880-2888. doi:10.1111/jocn.14876
  29. Sarabi N, Navipour H, Mohammadi E. Sexual Performance and Reproductive Health of Patients with an Ostomy: A Qualitative Content Analysis. Sex Disabil. 2017;35(2):171-183. doi:10.1007/S11195-017-9483-Y
  30. Moreira WC, Vera SO da, Sousa GN de, Araújo SNM, Damasceno CKCS, Andrade EMLR. Sexualidade de pacientes com estomias intestinais de eliminação Sexuality of patients with bowel elimination ostomy. Rev Pesqui Cuid é Fundam Online. 2017;9(2):495-502. doi:10.9789/2175-5361.2017.v9i2.495-502
  31. Kandemir D, Oskay Ü. Sexual Problems of Patients with Urostomy: A Qualitative Study. Sex Disabil. 2017;35(3):331-340. doi:10.1007/s11195-017-9494-8
  32. Medina-Rico M, Zárate-Velasco AM, Quiñonez A, López-Ramos H. Sexuality in People With Ostomies: A Literature Review. Sex Disabil. 2019;37(4):571-586. doi:10.1007/s11195-019-09604-4
  33. Habib A, Connor MJ, Boxall NE, Lamb BW, Miah S. Improving quality of life for Muslim patients requiring a stoma: A critical review of theological and psychosocial issues. Surg Pract. 2020;24(1):29-36. doi:10.1111/1744-1633.12409
  34. Bulkley J, McMullen CK, Hornbrook MC, et al. Spiritual well-being in long-term colorectal cancer survivors with ostomies. Psychooncology. 2013;22(11):2513-2521. doi:10.1002/pon.3318

 

Defining the High Output Stoma

Michelle Carr, BNursing, GradCertSTN, MClinNurs(Wound), MNursingSc(NP)
Nurse Practitioner, Wound Management/Stomal Therapy, Sunshine Coast University Hospital, Australia

Paris E. Purnell, RN STN MBA
Senior Manager , Global Clinical Education APAC, Hollister Incorporated, Illinois, US

Aims/Objectives To offer a new definition of the High Output Stoma (HOS) that encompasses all aspects of the phenomenon that is relevant to all health disciplines. To encourage consistency in terminology across all disciplines managing the patient with a HOS. To provide a platform from which further research into HOS can be conducted.

Purpose & Background HOS patients are at risk of developing complications leading to increased morbidity, mortality, reduced quality of life, increased length of hospital stays, and frequent hospital readmissions.1,5,6,7,8, 10. While the literature is paying increasing attention to the management of HOS, there are many elements of this condition that are yet to be researched in depth, for example, the incidence of HOS, health outcomes, financial cost to the health system and social cost to the community. Most interestingly, consensus has yet to be reached on what defines a HOS: the definition varies within and across the disciplines, and the principles underpinning the definitions are not fully described. 1,2,3,4,5

Methods Representing several countries, the authors undertook an extensive literature review, to understand the variety of definitions described, patient characteristics, and the aetiologies that influence the output of a stoma in order to gain a consensus for providing a new definition of a HOS that incorporates parameters such as the volume of output, time frames, anatomical variations, and biochemical markers.

Results The resulting definition will be shared at the Congress with a view to it gaining acceptance as the new standard global definition.

Conclusion/Outcome An accurate and clear definition of HOS should form the cornerstone for further discussion and research into the phenomenon allowing useful conclusions to be drawn that are relevant and consistent for promoting evidence-based practices, that ultimately benefits the patient with HOS.

Keywords high output, stoma, definition, ostomy

References

  1. Goodey & Colman, 2016, ‘Safe management of ileostomates with high-output stomas,’ British Journal of Nursing, 25(17):1–5.
  2. Baker ML, Williams, RN & Nightingale, JM, 2011, ‘Causes and management of a high-output stoma’, Colorectal Diseases, 13(2):191–197.
  3. McDonald A, 2014, ‘Orchestrating the management of patients with high output stomas’, British Journal of Nursing, 23(12):645–649.
  4. ASCN Stoma Care, Clinical Guidelines 2016, pp. 21-25.
  5. Mountford CG, Manas DM, Thompson NP. A practical approach to the management of high-output stoma. Frontline Gastroenterol. 2014 Jul;5(3):203-207. doi: 10.1136/flgastro-2013-100375. Epub 2013 Oct 31. PMID: 28839771; PMCID: PMC5369744.
  6. Lee YJ, Kweon, MR & Park, M. ‘Nutritional management of a patient with a high-output stoma after extensive small bowel resection to treat Crohn’s disease’, Clinical Nutrition Research, 2019. 8(3):247–253.
  7. Nasser, R, Parrish, CR, & Bridges, M. ‘High output ileostomies: The stakes are higher than the output’, 2019. Practical Gastroenterology, XLIII(9): 20-33.
  8. Chen, SY, Stem, M, Cerullo, M, Canner, JK, Gearhart, SL, Safar, B, Fang, SH & Efron, JE. ‘Predicting the risk of readmission from dehydration after ileostomy formation: The DRIP score’, 2018. Diseases of Colon & Rectum, 61(12):1410–1417.

 

War, Weather, Weapons and Wounds: W4

Michele R. Burdette-Taylor, PhD, MSN, RN, CWCN, CFCN, NPD-BC, LTC-R
Associate Professor, Saint Martin University, Washington, US

Aims/Objectives Identify intervention/s of foot and wound care in the 19th that influenced 21st century practices. Isolate the evolution of military combat and wound care according to types of weapons over time and weather-related injuries. Discuss the science “silver linings” of war and combat for development of technology, products, adjunctive/advanced therapies, and devices.

Purpose & Background To share the evidence-based research highlighted with personal and professional experience. As a retired military nurse who focused on wound care during Persian Gulf, Operation Enduring Freedom, Operation Iraqi Freedom and recently Ukraine and Israel Wars, this presentation is provides a unique opportunity to share for the ostomy and wound care colleagues world-wide. As a Nightingale Scholar investigating the military medical system interventions during the Crimean War and as a nurse passionate about the history of health and welfare of soldier. The purpose is to link the history of combat injuries related to weapons, weather-related issues and at-the-moment in time standard wound care management.

Methods Integrative review conducted of the historical, seminal, and current evidence to support how wound care nurses may utilise military interventions to facilitate successful healing in the civilian sector.

Results The extensive review of the literature results focused on the development of products, devices, adjunctive and advanced technologies to improve healing rates, reduce severity of amputations, and wounds. Since the Crimean War many inventions and interventions have evolved have been developed to facilitate healing of soldiers, while reducing morbidity and mortality.

Conclusion/Outcome Understanding the history allows for improvement of care while avoiding same or similar mistakes. Sharing with providers “how we got to where we are today” provides an enlightened ah-ha moment for ostomy and wound care nursing, from a five decade career in military and civilian wound care arenas.

Keywords adjunctive munitions, x-rays, antibiotics, communication

References

Enloe, C. (2019). Wounds: militarized nursing, feminist curiosity, and unending war. International Relations, 33, 393-412.

Gumeniuk, K., Lurin, I.A.,Tsema, I., Malynovska, L., Gorobeiko, M. & Dinets, A. (2023). Gunshot injury to the colon by expanding bullets in combat patients wounded in hybrid period of the Russian-Ukrainian war during 2014-2020. BMC Surgery, https://doi.org/10.1186/s12893-023-01919-6

Manring, M., Hawk, A. & Calhoun, J.H. (2009). Treatment of war wounds. Clinical Orthopedic Relations Research, 467, 2168-2191.

Nightingale, F. (1858). Notes on hospitals. John W. Parker and Son, West Strand, UK. - 2 papers read at the National Association for the Promotion of Social Science in Liverpool

Nightingale, F. (1858). Notes on matters on the health, efficiency, and hospital administration of the British Army founded chiefly on the experience of the late war. London; 860 pages, 1000 copies distributed.

Nightingale, F. (1860). Notes on nursing, what it is and what it is not. Pacific Publishing Studio by Madison Park, www.PacPS.com

Protas, M., Schumacher, M. Iwanaga, J., Yilmaz, E., Oskoulan, R.J. & Tubbs, S. (2018). Treatment of gunshot wounds to spine during late 19th century. World European Surgery, 115, 285-287.

 

Life with a long-term stoma across five European countries

Marianne Krogsgaard, PhD, Associate Professor
Clinical Nurse Specialist, Department of Surgery, Center for Surgial Science, Zealand University Hospital, Koege, Denmark; Department of People and Technology, Roskilde University, Denmark

Helle Kristensen, PhD MD
Department of Surgery, Aarhus University Hospital; Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects After Cancer in the Pelvic Organs, Denmark

Peter Christensen, Professor MD
Department of Surgery, Aarhus University Hospital; Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects After Cancer in the Pelvic Organs, Denmark

Aims/Objectives To examine the prevalence and impact of stoma-related problems on patients’ everyday life

Purpose & Background Follow-up policies are changing throughout the world in order to personalise follow-up to those patients most in need. Concurrently, a high prevalence of late effects following colorectal cancer surgery has been revealed. For stoma nurses to design future follow-up care for patients with a long-term stoma after rectal cancer, knowledge of the prevalence, type, and impact of stoma-related problems on patients’ everyday lives is needed. Such knowledge is lacking.

Methods We performed a cross-sectional study across five European countries on 2262 long-term survivors using validated patient-reported outcome measures. Stoma problems’ association with restrictions in everyday life was calculated using multivariable regression analysis that adjusted for potential confounding factors.

Results Stoma-related problems were highly prevalent 5.4 (IQR 3.8-7.6) years after stoma surgery; leakage from stoma onto skin (58%), troublesome odour (55%), skin problems (27%), and pain at stoma site (21%). Almost one in five patients (19%) was restricted in everyday life due to the stoma. Experiencing odour and leakage ≥1 per week, skin problems, and change frequency of stoma bag >4 times daily were significantly associated with restrictions.

Conclusion/Outcome A high prevalence of morbidity of colostomies was reported by patients. To potentially help patients restricted in everyday life, easy and swift access to stoma care nurses is warranted. Annual surveys or screening of stoma function and problems could be the first step towards long-term follow-up after stoma formation.

Keywords Rectal cancer, long-term survivor, stoma care, symptoms, daily living

 

When unprepared for the emergence of a parastomal bulge – a qualitative study

Marianne Krogsgaard, PhD, Associate Professor
Clinical Nurse Specialist, Department of Surgery, Center for Surgial Science, Zealand University Hospital, Koege, Denmark; Department of People and Technology, Roskilde University, Denmark

Pia Dreyer, Professor
Clinical Nurse Specialist, Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Denmark ; Department of Public Health, Section of Nursing Science, Aarhus University, Denmark

Thordis Thomsen, Professor
Department of Anaesthesiology, Herlev Hospital, University of Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Denmark

Aims/Objectives To investigate patients’ experiences of being prepared for the emergence of a parastomal bulge in relation to a stoma.

Purpose & Background Parastomal bulging has a significant impact on patients’ lives. We have limited information from the patient’s perspective on the information provided on parastomal bulging.

Methods Qualitative interviews with 20 patients participating in five focus groups. Analysis was performed using a three-phased phenomenological-hermeneutic approach inspired by Paul Ricoeur.

Results The unforeseen bulge gave rise to increasing concerns and worry about the cause and consequences of the bulging skin. Patients sought explanations in their own lives. In this way, one’s own behaviour or previous illness such as influenza, coughing, and efforts to rehabilitate after surgery, were suspected to have induced the bulge. Patients were under the impression that healthcare professionals knew about preventive interventions that patients were not informed about. Missing or conflicting information led to counterproductive behaviour and patients unknowingly carried on with hard and strenuous work after stoma surgery, a behaviour they would have refrained from had they known about the bulge. Patients were disappointed with healthcare professionals due to the lack of information. As patients found the bulge hard to live with, they sought the surgeon’s opinion and advice on surgical repair. Some patients were reassured not to undergo surgery and got on with their lives. Others were left with little hope of change.

Conclusion/Outcome Lack of information may lead to mistrust and disappointment with healthcare professionals. Addressing patients’ individual support needs and information needs is important to preserve patient autonomy and well-being. Surgeons and stoma nurses should be aware of the impact of their approach to communicating with patients about parastomal bulging.

Keywords parastomal bulge, hernia, information, preparation, qualitative

References

Krogsgaard M, Dreyer P, Thomsen T. Understanding patients’ perspectives when unprepared for the emergence of a parastomal bulge—a qualitative study. Colorectal Dis. 2023;00:1–8. https://doi.org/10.1111/ codi.16750

 

Effectiveness and Safety of Negative Pressure Wound Therapy on Melanoma-Resected Surgical Wounds

Kyoung Ae NAM
Wound Care Specialist, Yonsei University Severence Hospital, South Korea

Aims/Objectives  Negative pressure wound therapy (NPWT), a wound dressing system that provides sub-atmospheric pressure throughout the wound site, promotes wound healing, and reduces surgical complications. Although it is contraindicated in malignant wounds due to the potential risk of tumorigenesis, the evidence is limited.

Purpose & Background To compare tumor recurrence and wound healing performance, and surgical complications to provide evidence for the use of NPWT on melanoma-resected wounds.

Methods We retrospectively reviewed the medical records of 232 patients who were histopathologically diagnosed with acral lentiginous melanoma without nodal and distant metastasis between Jan 2006–Feb 2020. In all 179 patients received NPWT, and 53 patients received conventional surgical dressing.

Results Fifty one (28.5%) patients in the NPWT group had recurrence, of which 18 (10.1%) were local recurrence, 17 (32.1%) patients who received conventional surgical dressing had recurrence, of which 5 (9.4%) was local recurrence. There were no significant differences in recurrence-free survival between both group (Log rank test, P=0.701). Patients who received NPWT with skin grafting showed significantly faster wound healing compared to those who received conventional surgical dressing alone, and NPWT without skin grafting (P<0.001). Patients who received NPWT had lower surgical site infection rate than conventional surgical dressing (15.1% vs 28.3%, P=0.028).

Conclusion/Outcome NPWT does not significantly increase tumor recurrence in melanoma-resected wounds. Compared to conventional surgical dressing, NPWT offers several advantages in promoting wound healing and reducing surgical site infection.

Keywords negative pressure wound therapy (NPWT), melanoma-resected surgical wounds

References

  1. Venturi ML, Attinger CE, Mesbahi AN, Hess CL , Graw KS. Mechanisms and clinical applications of the vacuum-assisted closure (VAC) Device: a review. Am J Clin Dermatol 2005;6:185-94.
  2. Normandin S, Safran T, Winocour S, Chu CK, Vorstenbosch J, Murphy AM et al. Negative Pressure Wound Therapy: Mechanism of Action and Clinical Applications. Semin Plast Surg 2021;35:164-70.
  3. Wang YJ, Yao XF, Lin YS, Wang JY , Chang CC. Oncologic feasibility for negative pressure wound therapy application in surgical wounds: A meta-analysis. Int Wound J 2022;19:573-82.
  4. Hays TR, Singh G, Saragossi J, Park J, Shekar S, Marquez JE et al. Negative-Pressure Wound Therapy versus Standard Surgical Dressings after Malignant Tumor Resection: A Systematic Review and Meta-Analysis. Plast Reconstr Surg 2022;150:655e-70e.
  5. Andrades P, Figueroa M, Sepúlveda S, Benitez S, Erazo C , Danilla S. Tumor Recurrence after Negative Pressure Wound Therapy: An Alert Call. Case Reports in Clinical Medicine 2014;03:350-2.
  6. Cai SS, Gowda AU, Alexander RH, Silverman RP, Goldberg NH , Rasko YM. Use of negative pressure wound therapy on malignant wounds - a case report and review of literature. Int Wound J 2017;14:661-5.
  7. Putri IL, Adzalika LB, Pramanasari R , Wungu CDK. Negative pressure wound therapy versus conventional wound care in cancer surgical wounds: A meta-analysis of observational studies and randomised controlled trials. Int Wound J 2022;19:1578-93.
  8. Pflibsen LR, Lettieri SC, Kruger EA, Rebecca AM , Teven CM. Negative Pressure Wound Therapy in Malignancy: Always an Absolute Contraindication? Plast Reconstr Surg Glob Open 2020;8:e3007.
  9. Oh BH, Lee SH, Nam KA, Lee HB , Chung KY. Comparison of negative pressure wound therapy and secondary intention healing after excision of acral lentiginous melanoma on the foot. Br J Dermatol 2013;168:333-8.
  10. Mendez-Eastman S. Guidelines for Using Negative Pressure Wound Therapy. Advances in Skin & Wound Care 2001;14:314-23.

 

Negative Pressure Wound Therapy for Colorectal Incisions: A Systematic Review and Meta-Analysis of Controlled Trials

Ting-Kuang Wang
Nurse practitioner, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan

Chien-Hsin Chen M.D.
Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan

Kee-Hsin Chen
Assistant Professor, Post-Baccalaureate Program in Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan

Chiehfeng Chen M.D., Ph. D.
Taipei Medical University, Taipei, Taiwan

Aims/Objectives  Colorectal surgery carries a significantly higher risk of wound infection, showing an eightfold increase in adverse events compared to alternative procedures. Despite the growing popularity of minimally invasive approaches, open surgery remains the standard, particularly in complex conditions. Our study aims to evaluate the efficacy and safety of NPWT for colorectal incisions.

Purpose & Background Negative pressure wound therapy (NPWT) has demonstrated promising results for reducing surgical site infection (SSI) rates after orthopedic, vascular, cardiothoracic, plastic, and abdominal surgery. The literature on NPWT for colorectal incisions is growing, with several randomised controlled trials (RCTs), but findings have been inconsistent.

Methods The Cochrane Central Register of Controlled Trials, PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and ClinicalTrials.gov databases were searched for RCTs and non-randomised controlled trials (non-RCTs) comparing NPWT and standard care.

Results Five RCTs and six non-RCTs were included (n=2,193). NPWT significantly reduced the rate of infection in colorectal incisions (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.41 to 0.78; I2=14%; p<0.0005) and wound complications (OR, 0.33; 95% CI, 0.13 to 0.88; I2=59%; p=0.03). NPWT also shortened the wound healing time by 3 days (mean difference, −2.98; 95% CI, −4.99 to −0.97; I2=0%; p=0.004). Subgroup analysis revealed that NPWT conferred greater benefits on wounds resulting from life-threatening emergency surgery and contaminated or dirty wounds.

Conclusion/Outcome NPWT is an effective intervention for the closure of wounds in patients after colorectal surgery, that significant reduction of SSI, overall wound complications, mean complete wound healing time, and more effectively in emergency, and contaminated to dirty wounds. Treatment options should be considered in terms of cost benefits and adequate patient selection during shared decision-making.

Keywords negative pressure wound therapy, colorectal surgery, systematic review, meta-analysis

References

Murphy P, Lee K, Dubois L, et al. Negative pressure wound therapy for high-risk wounds in lower extremity revascularization: study protocol for a randomized controlled trial. Trials. 2015;16:504.

Gomoll AH, Lin A, Harris MB. Incisional Vacuum-Assisted Closure Therapy. Journal of orthopaedic trauma. 2006;20(10):705-709.

Fowler AL, Barry MK. Closed incision negative pressure therapy: Results of recent trials and recommendations for clinical practice. Surgeon. 2020;18(4):241-250.

O’Leary DP, Peirce C, Anglim B, et al. Prophylactic Negative Pressure Dressing Use in Closed Laparotomy Wounds Following  Abdominal Operations: A Randomized, Controlled, Open-label Trial: The P.I.C.O. Trial. Annals of surgery. 2017;265(6):1082-1086.

Shen P, Blackham AU, Lewis S, et al. Phase II Randomized Trial of Negative-Pressure Wound Therapy to Decrease Surgical Site Infection in Patients Undergoing Laparotomy for Gastrointestinal, Pancreatic, and Peritoneal Surface Malignancies. J Am Coll Surg. 2017;224(4):726-737.

 

Prevalence and risk factors of multidrug-resistant bacteria infection in patients with autoimmune bullous disease

Lei Guo
Nurse-in-charge, Hospital of Skin Diseases, Chinese Academy of Medical Sciences, China

Aims/Objectives Aim to summarise the prevalence and risk factors for multidrug-resistant bacteria (MDROs) infections of patients with autoimmune bullous disease (AIBD). In order to provide basis for the formulation of clinical prevention and nursing programs.

Purpose & Background The occurrence of infection in AIBD has a great negative impact on the treatment and control of the primary disease. Studies generally believed that the drug resistance rate of bacteria has been increasing in recent years, and the emergence of multi-drug resistant bacteria such as MRSA is not conducive to the control of subsequent wound infection. There is a lack of research on the high risk factors of skin infection with multi-drug resistant bacteria in patients with all autoimmune bullous diseases.

Methods A retrospective study was conducted to collect the information of 271 hospitalised patients with AIBD. Univariate and binary logistic regression were used to analyze the independent risk factors of multidrug-resistant bacteria infection in patients.

Results 440 patients with AIBD were treated within 3 years. The bacterial culture rate was 72.7% and the positive rate was 55.7%. 74 patients were infected with multi-drug resistant bacteria. Staphylococcus and Enterobacter were the main bacterial groups with multi-drug resistance, accounting for 75.9% and 13.9% respectively. There were statistically significant differences in the length of hospitalization, severity, self-modification of dosage, external use of antibiotic ointment, use of immunosuppressant, duration of glucocorticoids use, maximum dose of glucocorticoids and albumin value at the first admission between the two groups ( P < 0.05). Regression analysis showed that external use of antibiotic ointment, use of immunosuppressants, maximum dose of glucocorticoids and self-modification were independent risk factors for multidrug-resistant bacterial infection.

Conclusion/Outcome AIBD patients are prone to MDROs infections, with Staphylococcus being the most common multi-drug resistant pathogen.Topical antibiotic ointment, large use of immunosuppressants and glucocorticoids, self-modification of dosage will increase the risk of MDROs infection.

Keywords autoimmune bullous disease, wound Infection, multidrug-resistant

References

  1. Kutlubay Z, Sevim Keçici A, Çelik U et al. A survey of bullous diseases in a Turkish university hospital: clinicoepidemiological characteristics and follow-up. Turkish Journal Of Medical Sciences, 2021,51(1):124-133. DOI:10.3906/sag-2006-231.
  2. Chams-Davatchi C, Valikhani M, Daneshpazhooh M, et al. Pemphigus: analysis of 1209 cases. Int J Dermatol, 2005,44(6):470-476.. DOI:10.1111/j.1365-4632.2004.02501.x.
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  4. Amber K T, Murrell D F, Schmidt E, et al. Autoimmune Subepidermal Bullous Diseases of the Skin and Mucosae: Clinical Features, Diagnosis, and Management. Clinical Reviews in Allergy & Immunology, 2018,54(1):26-51. DOI:10.1007/s12016-017-8633-4.
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Resumos selecionados do 24º Congresso da Bienal WCET® em Glasgow, Reino Unido

DOI: 10.33235/wcet.44.4.39-47

PDF

Os delegados ao Congresso WCET®, em Glasgow, Reino Unido, em Setembro, foram recebidos com um programa científico bastante bem sucedido, de conteúdo diversificado, estimulante e de alta qualidade.

Para benefício dos muitos membros que não puderam comparecer, aqui podem encontrar uma amostra do que foi apresentado por oradores de todo o mundo.

Gestão da síndrome de ressecção anterior baixa

Jennie Burch, RN, BSc, MSc
Diretora de Formação de Enfermeiros Gastrointestinais, St Mark's Hospital, Londres, Reino Unido

Claire Taylor, RGN, PhD
Diretora de Enfermagem, Macmillan, Reino Unido

Ana Wilson, MD
Consultora de Gastroenterologista, St Mark's Hospital, Londres, Reino Unido

Christine Norton, RGN, PhD
Professora de Enfermagem, King's College London, Reino Unido

Finalidades/Objetivos O objetivo da apresentação passa por descrever a gestão de enfermagem dos sintomas do cólon irritável, sintomas esse que ocorrem após o tratamento do cancro rectal. Os objetivos passam por melhorar os conhecimentos e a confiança dos enfermeiros na prestação de cuidados a este grupo de pacientes.

Objetivo e Antecedentes Sabe-se que, em todo o mundo, todos os anos, cerca de um milhão de pessoas são diagnosticadas com cancro rectal (Emmertsen & Laurberg, 2013). O tratamento do cancro rectal consiste geralmente em cirurgia, acompanhada de quimioterapia e radioterapia, o que pode ter consequências como a disfunção intestinal, coletivamente designada por síndrome da ressecção anterior baixa ou LARS (Keane et al. 2020). O objetivo desta apresentação é o de aumentar os conhecimentos sobre a gestão da LARS após a cirurgia do cancro rectal.

Métodos Foi realizado um doutoramento com recurso a um projeto multifásico de métodos mistos para investigar a gestão da LARS. Uma revisão sistemática resumiu tematicamente a forma como as consequências do tratamento do cancro rectal afetam a qualidade de vida. Uma revisão do âmbito de aplicação enumerou os tratamentos disponíveis para gerir a LARS. As entrevistas descreveram tematicamente o que os pacientes necessitam para a gestão da LARS. Os grupos de discussão com pacientes e com clínicos descreveram tematicamente a forma como este objetivo pode ser alcançado.

Resultados Os resultados revelam que a qualidade de vida pode ser afetada negativamente pela LARS, sobretudo quando as pessoas não conseguem desempenhar as atividades que escolheram (Burch et al, 2021a). Existem várias opções para a gestão da LARS, mas os dados empíricos são limitados (Burch et al, 2021b). Os pacientes necessitam de clínicos bem informados que os interroguem sobre os sintomas e que os revisitem, fornecendo informações sobre estratégias de gestão e sinalizando outras informações relevantes (Burch et al, 2023a). Os médicos podem ajudar a definir expectativas para permitir um planeamento realista dos objetivos (Burch et al, 2023b). A gestão da LARS apoiada por enfermeiros pode melhorar os sintomas intestinais, conjuntamente com informações suplementares.

Conclusão/Resultados Em conclusão, um maior conhecimento sobre a LARS deverá aumentar a confiança dos enfermeiros para auxiliar os pacientes com cancro rectal a gerir os seus sintomas intestinais após o tratamento do cancro rectal. É necessária mais investigação para compreender a melhor forma de realizar intervenções LARS orientadas por enfermeiros.

Palavras-chave LARS, síndrome da ressecção anterior baixa, cancro rectal, enfermeiro, sobrevivência

Referências

Burch J., Taylor C., Wilson A., Norton C. (2021a) Symptoms affecting quality of life after sphincter-saving rectal cancer surgery: a systematic review. European Journal of Oncology Nursing, 52.

Burch J., Swatton A., Taylor C., Wilson A., Norton C. (2021b) Managing bowel symptoms after sphincter-saving rectal cancer surgery: a scoping review. Journal of Pain and Symptom Management 62(6), 1295-1307.

Burch J., Wright J., Taylor C., Wilson A., Norton C. (2023a) “He’s a surgeon, like I’m not going to waste his time”: interviews to determine healthcare needs for patients with low anterior resection syndrome (LARS) after rectal cancer surgery. Colorectal Disease 25, 880-887.

Burch J., Taylor C., Wilson A., Norton C. (2023b) “You’re just on your own”: Exploring bowel symptom management needs after rectal cancer surgery through patient and clinician focus groups. European Journal Oncology Nursing. https://doi.org/10.1016/j.ejon.2023.102406.

Emmertsen K.J., Laurberg S. (2013) Impact of bowel dysfunction on quality of life after sphincter-saving resection for rectal cancer. British Journal of Surgery 100(10), 1377-1387.

Keane C., Fearnhead N.S., Bordeianou L.G., Christensen P., Basany E.E., Laurberg S., Mellgren A., Messick C., Orangio G.R., Verjee A., Wing K., Bissett I. (2020) International consensus definition of low anterior resection syndrome. Diseases of the Colon & Rectum 63(3), 274-284.

 

Toda a minha vida tive de me adaptar ao meu estoma: Um estudo fenomenológico

Ria Andjarwati, médica, ONS, ETN,
Enfermeira-Chefe, Consultora de Feridas e Estomas, Enfermeira Especialista em Oncologia, Hospital do Centro Nacional de Cancro "dharmais", Indonésia

Yati Afiyanti, Prof. PhD. MN
Palestra honorária na Faculdade de Enfermagem da Universidade da Indonésia, Universidade da Indonésia, Indonésia

Finalidades/Objetivos O objetivo deste estudo foi o de descrever as experiências dos pacientes oncológicos no seu primeiro ano em que tiveram um estoma. Foi efetuado um estudo descritivo qualitativo.

Objetivo e Antecedentes Os pacientes com cancro e que são submetidos a uma cirurgia de estoma sofrem uma grande mudança na sua vida. Muitos problemas surgem a nível físico, psicológico, sexual e espiritual, especialmente no decurso do primeiro ano. O atraso no planeamento da alta em ambientes extra-hospitalares acontece frequentemente com os novos ostomizados, devido a uma deficiente educação e informação pré-operatórias. Ao explorar as experiências dos pacientes durante o período difícil da cirurgia do estoma, os prestadores de cuidados de saúde podem compreender melhor e dar aos pacientes os cuidados adequados.

Métodos Onze participantes foram convidados para entrevistas em profundidade semiestruturadas. Os dados foram analisados com recurso à análise temática.

Resultados Foram identificados dois temas: 1) Queixas durante o tratamento; 2). Adaptação à vida após o estoma. Ostomizados que enfrentam grandes mudanças na vida devido à adaptação à vida com o estoma. Muitos aspetos da vida dos ostomizados necessitam de ser ajustados. Ajustamento seguido de adaptação, finalmente reconhecido pelo ostomizado que entra nos seis meses anteriores.

Conclusão/Resultados Este estudo fornece aos enfermeiros e a outras pessoas uma visão das experiências dos ostomizados indonésios sobre os seus processos de adaptação física, psicológica, social, espiritual e sexual e os seus planos para as suas vidas futuras com estoma. É muito útil para os pacientes com cancro colorretal ou com outros tipos de cancro que se submetem a uma vida com um estoma colocado.

Palavras-chave pacientes com cancro, experiência, ostomizado, pós-operatório, estoma

Referências

  1. Alenezi A, McGrath I, Kimpton A, Livesay K. Quality of life among ostomy patients: A narrative literature review. J Clin Nurs. 2021;30(21-22):3111-3123. doi:10.1111/jocn.15840
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  3. Kugler CM, Breuing J, Rombey T, et al. The effect of preoperative stoma site marking on risk of stoma-related complications in patients with intestinal ostomy—protocol of a systematic review and meta-analysis. Syst Rev. 2021;10(1):1-8. doi:10.1186/s13643-021-01684-8
  4. Summers MC. The Effect of Ostomate-to-Ostomate Support on Psychosocial Adaptation to Stoma. Dr Nurs Pract Capstone Proj. 2018;28.
  5. Burch J. Post-discharge care for patients following stoma formation: what the nurse needs to know. Nurs Stand. 2017;31(51):41-45. doi:10.7748/ns.2017.e10198
  6. Capilla-Díaz C, Bonill-de las Nieves C, Hernández-Zambrano SM, et al. Living With an Intestinal Stoma: A Qualitative Systematic Review. Qual Health Res. 2019;29(9):1255-1265. doi:10.1177/1049732318820933
  7. Vonk-Klaassen SM, de Vocht HM, den Ouden MEM, Eddes EH, Schuurmans MJ. Ostomy-related problems and their impact on quality of life of colorectal cancer ostomates: a systematic review. Qual Life Res. 2016;25(1):125-133. doi:10.1007/s11136-015-1050-3
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  9. de Almeida Silva K, Duarte AX, Cruz AR, de Araújo LB, das Graças Pena G. Time after ostomy surgery and type of treatment are associated with quality of life changes in colorectal cancer patients with colostomy. PLoS One. 2020;15(12):1-17. doi:10.1371/JOURNAL.PONE.0239201
  10. Dibley L, Czuber-Dochan W, Wade T, et al. Patient Decision-Making about Emergency and Planned Stoma Surgery for IBD: A Qualitative Exploration of Patient and Clinician Perspectives. Inflamm Bowel Dis. 2018;24(2):235-246. doi:10.1093/ibd/izx043
  11. Cross AJ, Wooldrage K, Robbins EC, et al. Whole-colon investigation vs. flexible sigmoidoscopy for suspected colorectal cancer based on presenting symptoms and signs: a multicentre cohort study. Br J Cancer. 2019;120(2):154-164. doi:10.1038/s41416-018-0335-z
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  13. Jayarajah U, Samarasekera DN. Psychological adaptation to alteration of body image among stoma patients: A descriptive study. Indian J Psychol Med. 2017;39(1):63-68. doi:10.4103/0253-7176.198944
  14. Tiranda Y, Siripul P, Sangchart B, Septiwi C. Perspectives of adult survivors of colorectal cancer with an ostomy on their needs: Synthesis of qualitative research studies. Cent Eur J Nurs Midwifery. 2019;10(4):1155-1166. doi:10.15452/CEJNM.2019.10.0027
  15. Rafiei H, Hosseinzadeh K, Hoseinabadi-Farahani MJ, et al. The relationship between psychological health and spiritual wellbeing in Iranian stoma patients. Gastrointest Nurs. 2019;17:S18-S22. doi:10.12968/gasn.2019.17.Sup5.S18
  16. Rafiei H, Hoseinabadi-Farahani MJ, Aghaei S, Hosseinzadeh K, Naseh L, Heidari M. The prevalence of psychological problems among ostomy patients: A cross-sectional study from Iran. Gastrointest Nurs. 2017;15(2):39-44. doi:10.12968/gasn.2017.15.2.39
  17. Choudhary M, Kaur H. Experiences of living with intestinal ostomy: A qualitative meta-synthesis. Indian J Palliat Care. 2020;26(4):421-427. doi:10.4103/IJPC.IJPC_21_20
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  20. Marinez AC, Bock D, Carlsson E, et al. Stoma-related complications: a report from the Stoma-Const randomized controlled trial. Color Dis. 2021;23(5):1091-1101. doi:10.1111/codi.15494
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  22. Stelton S. CE: Stoma and Peristomal Skin Care: A Clinical Review. Am J Nurs. 2019;119(6):38-45. doi:10.1097/01.NAJ.0000559781.86311.64
  23. Correa Marinez A, Bock D, Carlsson E, et al. Stoma-related complications: a report from the Stoma-Const randomized controlled trial. Color Dis. 2021;23(5):1091-1101. doi:10.1111/codi.15494
  24. Rowe KM, Schiller LR. Ileostomy diarrhea: Pathophysiology and management. Baylor Univ Med Cent Proc. 2020;33(2):218-226. doi:10.1080/08998280.2020.1712926
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  26. Nam KH, Kim HY, Kim JH, Kang KN, Na SY, Han BH. Effects of social support and self-efficacy on the psychosocial adjustment of Korean ostomy patients. Int Wound J. 2019;16(October 2018):13-20. doi:10.1111/iwj.13038
  27. García-Rodríguez MT, Barreiro-Trillo A, Seijo-Bestilleiro R, González-Martin C. Sexual dysfunction in ostomized patients: A systematized review. Healthc. 2021;9(5):1-11. doi:10.3390/healthcare9050520
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Definição de estoma de alto débito

Michelle Carr, BNursing, GradCertSTN, MClinNurs(Wound), MNursingSc (NP)
Enfermeira, Gestão de Feridas/Terapia Estomal, Sunshine Coast University Hospital, Austrália

Paris E. Purnell, RN STN MBA
Diretora Sénior, Educação Clínica Global APAC, Hollister Incorporated, Illinois, EUA

Finalidades/Objetivos Oferecer uma nova definição de estoma de alto débito (HOS) que englobe todos os aspetos do tema e que seja relevante para todas as disciplinas da saúde. Incentivar a coerência da terminologia em todas as disciplinas que gerem o paciente com uma HOS. Fornecer uma plataforma a partir da qual possa ser conduzida mais investigação sobre o HOS.

Objetivo e Antecedentes Os pacientes com HOS apresentam o risco de desenvolver complicações que conduzem a um aumento da morbilidade, mortalidade, redução da qualidade de vida, aumento do tempo de internamento hospitalar e ainda reinternamentos frequentes1,5,6,7,8,10. Embora a literatura esteja a prestar cada vez mais atenção à gestão do HOS, existem muitos elementos desta doença que ainda não foram investigados em profundidade, tais como, a incidência do HOS, os resultados em termos de saúde, o custo financeiro para o sistema de saúde e o custo social para a comunidade. O mais interessante é que ainda não se chegou a um consenso sobre o que define um HOS: a definição varia dentro e entre as disciplinas e os princípios subjacentes às definições não estão totalmente descritos. 1,2,3,4,5

Métodos Representando vários países, os autores realizaram uma extensa revisão da literatura, de forma a compreender a variedade de definições descritas, as caraterísticas dos pacientes e as etiologias que influenciam o débito de um estoma, com o fim de obter um consenso para estabelecer uma nova definição de HOS que incorpore parâmetros como o volume de débito, os períodos de tempo, as variações anatómicas e os marcadores bioquímicos.

Resultados A definição resultante será partilhada no Congresso com a intenção de ser aceite como a nova definição global padrão.

Conclusão/Resultados Uma definição exata e clara do HOS deve constituir a pedra angular de um debate e de uma investigação mais aprofundados sobre o tema, permitindo retirar conclusões úteis, relevantes e consistentes para a promoção de práticas baseadas em evidências, que, em última análise, beneficiam o paciente com HOS.

Palavras-chave alto débito, estoma, definição, ostomia

Referências

  1. Goodey & Colman, 2016, ‘Safe management of ileostomates with high-output stomas,’ British Journal of Nursing, 25(17):1–5.
  2. Baker ML, Williams, RN & Nightingale, JM, 2011, ‘Causes and management of a high-output stoma’, Colorectal Diseases, 13(2):191–197.
  3. McDonald A, 2014, ‘Orchestrating the management of patients with high output stomas’, British Journal of Nursing, 23(12):645–649.
  4. ASCN Stoma Care, Clinical Guidelines 2016, pp. 21-25.
  5. Mountford CG, Manas DM, Thompson NP. A practical approach to the management of high-output stoma. Frontline Gastroenterol. 2014 Jul;5(3):203-207. doi: 10.1136/flgastro-2013-100375. Epub 2013 Oct 31. PMID: 28839771; PMCID: PMC5369744.
  6. Lee YJ, Kweon, MR & Park, M. ‘Nutritional management of a patient with a high-output stoma after extensive small bowel resection to treat Crohn’s disease’, Clinical Nutrition Research, 2019. 8(3):247–253.
  7. Nasser, R, Parrish, CR, & Bridges, M. ‘High output ileostomies: The stakes are higher than the output’, 2019. Practical Gastroenterology, XLIII(9): 20-33.
  8. Chen, SY, Stem, M, Cerullo, M, Canner, JK, Gearhart, SL, Safar, B, Fang, SH & Efron, JE. ‘Predicting the risk of readmission from dehydration after ileostomy formation: The DRIP score’, 2018. Diseases of Colon & Rectum, 61(12):1410–1417.

 

Guerra, clima, armas e ferimentos: W4

Michele R. Burdette-Taylor, PhD, MSN, RN, CWCN, CFCN, NPD-BC, LTC-R
Professora Associada, Saint Martin University, Washington, EUA

Finalidades/Objectivos Identificar a(s) intervenção(ões) de tratamentos de pés e de feridas no século XIX que vieram a influenciar as práticas do século XXI. Isolar a evolução do combate militar e dos tratamentos de feridas de acordo com os tipos de armas ao longo do tempo, assim como as lesões relacionadas com o clima. Discutir os "efeitos positivos" da ciência da guerra e do combate para o desenvolvimento de tecnologia, produtos, terapias adjuvantes/avançadas e dispositivos.

Objetivo & Antecedentes Partilhar a investigação baseada em evidências, realçada pela experiência pessoal e profissional. Na qualidade de enfermeiro militar reformado que se dedicou ao tratamento de feridas durante as Guerras do Golfo Pérsico, Operação Liberdade Duradoura, Operação Liberdade Iraquiana e recentemente Ucrânia e Israel, esta apresentação constitui uma oportunidade única de partilha para os colegas de cuidados de ostomia e de feridas de todo o mundo. Enquanto bolseiro Nightingale, investigou as intervenções do sistema médico militar durante a Guerra da Crimeia e enquanto enfermeiro apaixonou-se pela história da saúde e do bem-estar dos soldados. O objetivo consiste em estabelecer uma ligação entre a história dos ferimentos de combate relacionados com as armas, as questões referentes às condições meteorológicas e o tratamento normalizado dos ferimentos no momento.

Métodos Foi efetuada uma revisão integrativa das provas históricas, iniciais e atuais para apoiar a forma como os enfermeiros que tratam de feridas podem utilizar as intervenções militares de forma a facilitar uma cura bem sucedida no sector civil.

Resultados A extensa revisão dos resultados da literatura centrou-se no desenvolvimento de produtos, dispositivos, tecnologias adjuvantes e avançadas para melhorar as taxas de cicatrização, reduzir a gravidade das amputações e das feridas. Desde a Guerra da Crimeia, foram desenvolvidas muitas invenções e intervenções para facilitar a cura dos soldados, reduzindo simultaneamente a morbilidade e a mortalidade.

Conclusão/Resultados A compreensão do historial permite melhorar os cuidados de saúde e evitar erros iguais ou semelhantes. Partilhar com os prestadores de cuidados "como chegámos onde estamos hoje" proporciona um momento de aprendizagem para a enfermagem de ostomia e de tratamento de feridas, a partir de uma carreira de cinco décadas nos domínios de tratamento de feridas militares e civis.

Palavras-chave munições adjuvantes, raios X, antibióticos, comunicação

Referências

Enloe, C. (2019). Wounds: militarized nursing, feminist curiosity, and unending war. International Relations, 33, 393-412.

Gumeniuk, K., Lurin, I.A.,Tsema, I., Malynovska, L., Gorobeiko, M. & Dinets, A. (2023). Gunshot injury to the colon by expanding bullets in combat patients wounded in hybrid period of the Russian-Ukrainian war during 2014-2020. BMC Surgery, https://doi.org/10.1186/s12893-023-01919-6

Manring, M., Hawk, A. & Calhoun, J.H. (2009). Treatment of war wounds. Clinical Orthopedic Relations Research, 467, 2168-2191.

Nightingale, F. (1858). Notes on hospitals. John W. Parker and Son, West Strand, UK. - 2 papers read at the National Association for the Promotion of Social Science in Liverpool

Nightingale, F. (1858). Notes on matters on the health, efficiency, and hospital administration of the British Army founded chiefly on the experience of the late war. London; 860 pages, 1000 copies distributed.

Nightingale, F. (1860). Notes on nursing, what it is and what it is not. Pacific Publishing Studio by Madison Park, www.PacPS.com

Protas, M., Schumacher, M. Iwanaga, J., Yilmaz, E., Oskoulan, R.J. & Tubbs, S. (2018). Treatment of gunshot wounds to spine during late 19th century. World European Surgery, 115, 285-287.

 

A vida com um estoma de longa duração em cinco países Europeus

Marianne Krogsgaard, PhD, Professor Associado
Especialista em Enfermagem Clínica, Departamento de Cirurgia, Centro de Ciências Cirúrgicas, Hospital Universitário da Zelândia, Koege, Dinamarca; Departamento de Pessoas e Tecnologia, Universidade de Roskilde, Dinamarca

Helle Kristensen, PhD MD
Departamento de Cirurgia, Hospital Universitário de Aarhus; Sociedade Dinamarquesa do Cancro Centro de Investigação sobre Sobrevivência e Efeitos Adversos Tardios após Cancro nos Órgãos Pélvicos, Dinamarca

Peter Christensen, Professor MD
Departamento de Cirurgia, Hospital Universitário de Aarhus; Sociedade Dinamarquesa do Cancro Centro de Investigação sobre Sobrevivência e Efeitos Adversos Tardios após Cancro nos Órgãos Pélvicos, Dinamarca

Finalidades/Objectivos Examinar a prevalência e o impacto dos problemas relacionados com o estoma na vida quotidiana dos pacientes

Objetivo e Antecedentes As políticas de acompanhamento estão a mudar em todo o mundo, a fim de personalizar o seguimento dos pacientes mais necessitados. Ao mesmo tempo, foi detetada uma elevada prevalência de efeitos tardios após a cirurgia do cancro colorretal. Para que os enfermeiros especializados em estomas possam conceber os futuros cuidados de acompanhamento dos pacientes com um estoma de longa duração na sequência de um cancro rectal, é necessário conhecer a prevalência, o tipo e o impacto dos problemas relacionados com o estoma na vida quotidiana dos pacientes. Não existe este tipo de conhecimento.

Métodos Realizou-se um estudo transversal em cinco países europeus com 2262 sobreviventes de longa duração, utilizando medidas validadas de resultados reportados pelos pacientes. A associação dos problemas do estoma com as restrições na vida quotidiana foi calculada através de uma análise de regressão multivariada, a qual ajustou os potenciais fatores de perturbação.

Resultados Os problemas relacionados com o estoma foram altamente prevalentes 5,4 (IQR 3,8-7,6) anos após a cirurgia do estoma; fuga do estoma para a pele (58%), odor incómodo (55%), problemas de pele (27%) e dor no local do estoma (21%). Quase um em cada cinco pacientes (19%) tinha restrições na vida quotidiana originadas pelo estoma. Sentir odor e fugas ≥1 por semana, problemas de pele e frequência de mudança do saco do estoma >4 vezes por dia foram aspetos significativamente associados a restrições.

Conclusão/Resultados Os pacientes referiram uma elevada prevalência de morbilidade associada às colostomias. Para melhor auxiliar os pacientes com restrições na vida quotidiana, é necessário um acesso fácil e rápido a enfermeiros especializados no tratamento de estomas. Os inquéritos anuais ou o rastreio da funcionalidade e dos problemas do estoma podem ser o primeiro passo para um acompanhamento a longo prazo após a formação do estoma.

Palavras-chave Cancro rectal, sobrevivente a longo prazo, cuidados com o estoma, sintomas, vida quotidiana

 

Quando não se está preparado para o surgimento de uma protuberância paraestomal - um estudo qualitativo

Marianne Krogsgaard, PhD, Professor Associado
Especialista em Enfermagem Clínica, Departamento de Cirurgia, Centro de Ciências Cirúrgicas, Hospital Universitário da Zelândia, Koege, Dinamarca; Departamento de Pessoas e Tecnologia, Universidade de Roskilde, Dinamarca

Pia Dreyer, Professor
Especialista em Enfermagem Clínica, Departamento de Anestesiologia e Cuidados Intensivos, Hospital Universitário de Aarhus, Dinamarca; Departamento de Saúde Pública, Secção de Ciências de Enfermagem, Universidade de Aarhus, Dinamarca

Thordis Thomsen, Professor
Departamento de Anestesiologia, Hospital Herlev, Universidade de Copenhaga, Dinamarca; Departamento de Medicina Clínica, Faculdade de Ciências da Saúde, Universidade de Copenhaga, Dinamarca

Finalidades/Objectivos Investigar as experiências dos pacientes sobre a sua preparação para o aparecimento de uma protuberância paraestomal em consequência de um estoma.

Objetivo e Antecedentes A protuberância paraestomal tem um impacto significativo na vida dos pacientes. A informação fornecida sobre a protuberância paraestomal é limitada do ponto de vista do paciente.

Métodos Entrevistas qualitativas a 20 pacientes que participaram em cinco grupos de discussão. A análise foi efetuada através de uma abordagem fenomenológica-hermenêutica em três fases, inspirada em Paul Ricoeur.

Resultados A protuberância imprevista deu origem a preocupações e a inquietações crescentes sobre a causa e as consequências da pele protuberante. Os pacientes procuraram explicações nas suas experiências pessoais. Desta forma, suspeitava-se que o próprio comportamento ou uma doença anterior, como a gripe, tosse e esforços de reabilitação após uma cirurgia, tivessem induzido o inchaço. Os pacientes tinham a sensação de que os profissionais de saúde conheciam intervenções preventivas sobre as quais os pacientes não estavam informados. Informações em falta ou contraditórias levaram a um comportamento contraproducente e os pacientes continuaram, sem saber, a fazer trabalhos pesados e extenuantes após a cirurgia ao estoma, um comportamento de que se teriam abstraído se tivessem tido conhecimento da protuberância. Os pacientes ficaram desapontados com os profissionais de saúde devido à falta de informação. Como os pacientes tinham dificuldade em viver com a protuberância, procuravam a opinião e o aconselhamento do cirurgião sobre a correção cirúrgica. Alguns pacientes foram tranquilizados para não se submeterem a uma cirurgia e continuaram com as suas vidas. Outros ficaram com poucas esperanças de mudança.

Conclusão/Resultados A falta de informação pode levar à desconfiança e à desilusão para com os profissionais de saúde. A resposta às necessidades individuais de apoio e de informação por parte dos pacientes é importante para preservar a sua autonomia e bem-estar. Os cirurgiões e os enfermeiros responsáveis pelos estomas devem estar conscientes do impacto da sua abordagem à comunicação com os pacientes sobre o inchaço paraestomal.

Palavras-chave inchaço paraestomal, hérnia, informação, preparação, qualitativo

Referências

Krogsgaard M, Dreyer P, Thomsen T. Understanding patients’ perspectives when unprepared for the emergence of a parastomal bulge—a qualitative study. Colorectal Dis. 2023;00:1–8. https://doi.org/10.1111/ codi.16750

 

Eficácia e Segurança da Terapia de Feridas por Pressão Negativa em Feridas Cirúrgicas com Melanoma

Kyoung Ae NAM
Especialista em tratamento de feridas, Yonsei University Severence Hospital, Coreia do Sul

Finalidades/Objectivos A terapia de feridas por pressão negativa (NPWT), um sistema de penso para feridas que exerce uma pressão subatmosférica em todo o local da ferida, promovendo a cicatrização da ferida e a redução das complicações cirúrgicas. Embora esteja contraindicado em feridas malignas devido ao risco potencial de tumorigénese, as evidências são limitadas.

Objetivo e Antecedentes Comparar a recorrência do tumor e o desempenho na cicatrização da ferida, bem como possíveis complicações cirúrgicas, para proporcionar evidências da utilização da NPWT em feridas ressecadas por melanoma.

Métodos Foram revistos retrospetivamente os registos médicos de 232 pacientes a quem foi diagnosticado histo patologicamente melanoma lentiginoso acral sem metástases nodais, durante o período entre janeiro de 2006 e fevereiro de 2020. No total, 179 pacientes receberam NPWT e 53 pacientes receberam pensos cirúrgicos convencionais.

Resultados Cinquenta e um (28,5%) pacientes no grupo da NPWT apresentaram recidiva, dos quais 18 (10,1%) tiveram recidiva local; 17 (32,1%) pacientes que receberam penso cirúrgico convencional apresentaram recidiva, dos quais 5 (9,4%) foram recidiva local. Não se registaram diferenças significativas na sobrevivência isenta de recorrência entre os dois grupos (teste Log rank, P=0,701). Os pacientes que receberam NPWT com enxerto de pele apresentaram uma cicatrização significativamente mais rápida da ferida, em comparação com aqueles que receberam apenas o penso cirúrgico convencional e NPWT sem enxerto de pele (P<0,001). Os pacientes que receberam NPWT apresentaram uma taxa de infeção do local cirúrgico inferior à do penso cirúrgico convencional (15,1% vs 28,3%, P=0,028).

Conclusão/Resultados A NPWT não contribui significativamente para a recorrência do tumor em feridas ressecadas por melanoma. Em comparação com os pensos cirúrgicos convencionais, a NPWT oferece várias vantagens na melhoria da cicatrização de feridas e na redução da infeção do local cirúrgico.

Palavras-chave terapia de feridas por pressão negativa (NPWT), feridas cirúrgicas ressecadas por melanoma

Referências

  1. Venturi ML, Attinger CE, Mesbahi AN, Hess CL , Graw KS. Mechanisms and clinical applications of the vacuum-assisted closure (VAC) Device: a review. Am J Clin Dermatol 2005;6:185-94.
  2. Normandin S, Safran T, Winocour S, Chu CK, Vorstenbosch J, Murphy AM et al. Negative Pressure Wound Therapy: Mechanism of Action and Clinical Applications. Semin Plast Surg 2021;35:164-70.
  3. Wang YJ, Yao XF, Lin YS, Wang JY , Chang CC. Oncologic feasibility for negative pressure wound therapy application in surgical wounds: A meta-analysis. Int Wound J 2022;19:573-82.
  4. Hays TR, Singh G, Saragossi J, Park J, Shekar S, Marquez JE et al. Negative-Pressure Wound Therapy versus Standard Surgical Dressings after Malignant Tumor Resection: A Systematic Review and Meta-Analysis. Plast Reconstr Surg 2022;150:655e-70e.
  5. Andrades P, Figueroa M, Sepúlveda S, Benitez S, Erazo C , Danilla S. Tumor Recurrence after Negative Pressure Wound Therapy: An Alert Call. Case Reports in Clinical Medicine 2014;03:350-2.
  6. Cai SS, Gowda AU, Alexander RH, Silverman RP, Goldberg NH , Rasko YM. Use of negative pressure wound therapy on malignant wounds - a case report and review of literature. Int Wound J 2017;14:661-5.
  7. Putri IL, Adzalika LB, Pramanasari R , Wungu CDK. Negative pressure wound therapy versus conventional wound care in cancer surgical wounds: A meta-analysis of observational studies and randomised controlled trials. Int Wound J 2022;19:1578-93.
  8. Pflibsen LR, Lettieri SC, Kruger EA, Rebecca AM , Teven CM. Negative Pressure Wound Therapy in Malignancy: Always an Absolute Contraindication? Plast Reconstr Surg Glob Open 2020;8:e3007.
  9. Oh BH, Lee SH, Nam KA, Lee HB , Chung KY. Comparison of negative pressure wound therapy and secondary intention healing after excision of acral lentiginous melanoma on the foot. Br J Dermatol 2013;168:333-8.
  10. Mendez-Eastman S. Guidelines for Using Negative Pressure Wound Therapy. Advances in Skin & Wound Care 2001;14:314-23.

 

Terapia de Feridas por Pressão Negativa em Incisões Colorretais: Uma revisão sistemática e meta-análise de ensaios controlados

Ting-Kuang Wang
Enfermeiro, Hospital Wan Fang, Universidade de Medicina de Taipei, Taipei, Taiwan

Chien-Hsin Chen M.D.
Hospital Wan Fang, Universidade de Medicina de Taipei, Taipei, Taiwan

Kee-Hsin Chen
Professor Assistente, Programa de Pós-Bacharelato em Enfermagem, Faculdade de Enfermagem, Universidade Médica de Taipei, Taipei, Taiwan

Chiehfeng Chen M.D., Ph.D. D.
Universidade de Medicina de Taipei, Taipei, Taiwan

Finalidades/Objetivos A cirurgia colorretal comporta um risco significativamente mais elevado de infeção da ferida, apresentando um incremento de oito vezes nos eventos adversos, em comparação com procedimentos alternativos. Apesar da crescente popularidade das abordagens menos invasivas, a cirurgia aberta continua a ser o padrão, particularmente em condições complexas. O nosso estudo tem como objetivo a avaliação da eficácia e da segurança da NPWT em incisões colorretais.

Objetivo e Antecedentes A terapia de feridas por pressão negativa (NPWT) tem demonstrado resultados promissores na redução das taxas de infeção do local cirúrgico (SSI) na sequência de cirurgias ortopédicas, vasculares, cardiotorácicas, plásticas e abdominais. A literatura sobre NPWT para incisões colorretais está a crescer, com vários ensaios aleatórios controlados (RCTs), mas os resultados têm sido inconsistentes.

Métodos Foram pesquisadas as bases de dados Cochrane Central Register of Controlled Trials, PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature e a ClinicalTrials.gov para identificar ensaios aleatórios controlados e ensaios não aleatórios controlados (não RCTs) que comparassem a NPWT e os cuidados padrão.

Resultados Foram incluídos cinco ensaios clínicos RCT e seis não RCT (n=2 193). A NPWT reduziu significativamente a taxa de infeção nas incisões colorretais (rácio de probabilidades [OR], 0,57; intervalo de confiança [IC] de 95%, 0,41 a 0,78; I2=14%; p<0,0005) e as complicações da ferida (OR, 0,33; IC de 95%, 0,13 a 0,88; I2=59%; p=0,03). A NPWT também reduziu o tempo de cicatrização da ferida em 3 dias (diferença média, -2,98; IC 95%, -4,99 a -0,97; I2=0%; p=0,004). A análise de subgrupo revelou que a NPWT conferiu maiores benefícios em feridas resultantes de cirurgia de emergência com risco de vida e em feridas contaminadas ou com sujidade.

Conclusão/Resultados A NPWT é uma intervenção eficaz para o fecho de feridas em pacientes após cirurgia colorretal, com uma redução significativa de SSI, das complicações globais da ferida, do tempo médio de cicatrização completa da ferida e mais eficaz em feridas de emergência e contaminadas a sujas. As opções de tratamento devem ser consideradas em termos de custo-benefício e da seleção adequada dos pacientes durante a tomada de decisão conjunta.

Palavras-chave terapia de feridas por pressão negativa, cirurgia colorretal, revisão sistemática, meta-análise

Referências

Murphy P, Lee K, Dubois L, et al. Negative pressure wound therapy for high-risk wounds in lower extremity revascularization: study protocol for a randomized controlled trial. Trials. 2015;16:504.

Gomoll AH, Lin A, Harris MB. Incisional Vacuum-Assisted Closure Therapy. Journal of orthopaedic trauma. 2006;20(10):705-709.

Fowler AL, Barry MK. Closed incision negative pressure therapy: Results of recent trials and recommendations for clinical practice. Surgeon. 2020;18(4):241-250.

O’Leary DP, Peirce C, Anglim B, et al. Prophylactic Negative Pressure Dressing Use in Closed Laparotomy Wounds Following Abdominal Operations: A Randomized, Controlled, Open-label Trial: The P.I.C.O. Trial. Annals of surgery. 2017;265(6):1082-1086.

Shen P, Blackham AU, Lewis S, et al. Phase II Randomized Trial of Negative-Pressure Wound Therapy to Decrease Surgical Site Infection in Patients Undergoing Laparotomy for Gastrointestinal, Pancreatic, and Peritoneal Surface Malignancies. J Am Coll Surg. 2017;224(4):726-737.

 

Prevalência e fatores de risco de infeção por bactérias multirresistentes em pacientes com doença bolhosa autoimune

Lei Guo
Enfermeiro responsável, Hospital de Doenças da Pele, Academia Chinesa de Ciências Médicas, China

Finalidades/Objetivos O objetivo é resumir a prevalência e os fatores de risco das infeções por bactérias multirresistentes (MDROs) em pacientes com doença bolhosa autoimune (AIBD). A fim de fornecer bases para a formulação de programas de prevenção clínica e de enfermagem.

Objetivo e Antecedentes A ocorrência de infeção na AIBD tem um grande impacto negativo no tratamento e controlo da doença primária. De um modo geral, os estudos consideram que a taxa de resistência das bactérias aos medicamentos tem vindo a aumentar nos últimos anos e que o aparecimento de bactérias multirresistentes, tais como o MRSA, não favorece o controlo da infeção subsequente da ferida. Há falta de investigação relativamente aos fatores de alto risco de infeção cutânea com bactérias multirresistentes em pacientes em todas as doenças bolhosas autoimunes.

Métodos Foi realizado um estudo retrospetivo para recolher informações de 271 pacientes hospitalizados com AIBD. A regressão logística univariada e binária foi utilizada para analisar nos pacientes os fatores de risco independentes da infeção por bactérias multirresistentes.

Resultados 440 pacientes com AIBD foram tratados num período de 3 anos. A taxa de cultura bacteriana foi de 72,7% e a taxa positiva foi de 55,7%. 74 pacientes encontravam-se infetados com bactérias multirresistentes. Staphylococcus e Enterobacter constituíram os principais grupos bacterianos com multirresistência, representando 75,9% e 13,9%, respetivamente. Entre os dois grupos verificaram-se diferenças estatisticamente significativas no tempo de internamento, gravidade, auto-modificação da dose, uso externo de pomada antibiótica, uso de imunossupressor, tempo de uso de glucocorticoides, dose máxima de glucocorticoides e valor de albumina na primeira admissão ( P < 0,05). A análise de regressão mostrou que a utilização externa de pomada antibiótica, a utilização de imunossupressores, a dose máxima de glucocorticoides e a auto-modificação constituíam fatores de risco independentes para a infeção bacteriana multirresistente.

Conclusões/Resultados Os pacientes com AIBD são propensos a infeções por MDROs, sendo o Staphylococcus o agente patogénico multirresistente mais comum. As pomadas antibióticas tópicas, a utilização intensiva de imunossupressores e glucocorticoides e a auto-modificação da dosagem aumentam o risco de infeção por MDROs.

Palavras-chave doença bolhosa autoimune, Infeção da ferida, multirresistente

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