PRESSURE SORES
ByDr Zahid Iqbal Bhatti
Trainee Registrar
Definition Soft tissue injuries resulting from
unrelieved pressure over bony prominences.
The Term “Bed sores or decubitus ulcer” should be avoided as they point out that all the sores are the result of supine position.
In the lying position,the tissue destruction can occur over sacrum, scalp, shoulders, calves,and heels.
In the sitting or wheel chair position, the sores develop at the ischial area.
Relieving the pressure is the key factor to healing and key to prevention.
Poor nutrition, incontinence with persistent soilage and moisture, dementia, paralysis and friction make the healing less likely.
Risk factors
Age Impaired sensory perception Moisture Immobility Poor Nutrition Friction
Stages of Pressure Sores
Stage 1. skin
Intact but reddened for more than one hour after relief of pressure
Stage 2
Blister or other break in the dermis with or without infection.
Stage 3 subcutaneou
s destruction in to the muscle with or without infection
.
Stage 4
Involvement of the bone or joint with or without infection
What is seen on the surface is
often the tip of ICE BURG In general, approximately 9% of all
hospitalized develop pressure sores
Pathophysiology
Factors involved 1. Pressure 2. Infection 3. Edema 4. Altered Neurological state
Factors involved 1. Pressure 2. Infection 3. Edema 4. Altered Neurological state
Pathophysiology
Compression of the soft tissue results in ischemia and if not relieved, will progress to necrosis and ulceration even in the vascularized area
In Susceptible patients, it is accelerated by infection, inflammation and edema.
Cont- If the external pressure exceeds
capillary bed pressure, capillary perfusion is impaired and ischemia results.
There is an inverse relationship between the amount of pressure and the length of time required to cause ulceration.
.
Cont-
The initial pathological changes occur in the muscles overlying the bones followed by more superficial tissue and skin in last
Denervated and compressed skin becomes edematous which plays an important role in the pressure sore formation.
PREOPERATIVE CARE Preparing the patient & family for long
term management requires team approach:
Internal medicine Endocrinology Neurology Urology Nutritionist Physical & occupational therapy Psychiatry Specialist Nurse
Cont-
Care of the pressure sore is not only the care of the wound.
It includes the systemic strategy including nutritional assessment and maintenance, control of infection both local and systemic and pressure and spasm relief.
Preoperative care
Nutrition Treatment of infection Relief of pressure Management of spasm Contracture therapy
1-Nutrition Normal healing potential exists
when the serum albumin is above 2.0 g/dl
Daily requirement of person 1.5-3.0 g/dl of protein and 25-35 cal/kg of non protein
Exercise should be added to increase protein synthesis and anabolic drive.
Vitamin C and A and Zinc .
2-Infection Pressure sores may or may not be
present with local infection If infection present ,should be
debrided either at bed site or O.R. and small amount sent for microbiology
Swabbing should be avoided Antibiotics (Local or systemic) if
infection or Escher present.
These are at the risk of UTI and RTI infections.
If present UTI treated by antibiotic and change of catheter if present.
If Pneumonia then Positioning, side to side rolling, deep breathing and chest physiotherapy with bronchodilators.
3-Relief of Pressure This should be the prime goal. Healing will not occur in the
presence of ischemia or infection.
Frequent turning and intermittent elevation of the hips in the wheel chair
Various mattress and wheelchair padding.
Management of spasm Most common in spinal cord injuries
100% in cervical 75% in thoracic 50% in thoracolumber
Medications Diazepam ( valium ) 10mg every 4
to 6 hours Baclofen ( Lioresal ) 5mg every 6
hours Dantrolene ( Dantrium ) 25mg every
12 hours.
Contracture therapy
Tightening of muscle & joint capsule
Physiotherapy Tenotomies
SURGICAL &
NON SURGICALTREATMENT
Non surgical treatment
Some patients may never be candidate for surgical correction due to medical problems Avoidance of unrelieved pressure Control of infection Control of incontinence Improved nutrition
Surgical treatment Three principles1. Excisional debridment of the
ulcer, its bursa, and any calcification.
2. Partial or complete ostectomy to reduce the bony prominence.
3. Wound closure with healthy tissue.
1-DEBRIDEMENT
DEBRIDEMENT of any dead, necrotic tissue after instillation of methylene blue and Hdrogen peroxide .
Viable tissue specimen sent for quantitative culture
Post operatively, wound packed and dressing changed every 6-8 hrs.
2-OSTECTOMY
Removal of bony prominences in an integral part of surgical treatment of bed sores.
Radical Ostectomy avoided. Removing minimum amount of
bone necessary.
3-PRESSURE SORE CLOSURE
Considering not only the present surgery but also need for subsequent Procedure.
Choice depends upon site, size, depth and previous surgery.
Primary closure avoided. Skin Grafting has 30% success rate. Use of flaps
Pressure sore closure
Advantage of Musculocutaneous flap:
1. Excellent blood supply2. Provision of bulky padding 3. Ability to readvance or rotate
flaps to treat recurrence.
Pressure sore closure
Disadvantages:1. Tissue most sensitive to external
pressure.2. May be atrophic in elder patients.3. Functional deformity in
ambulatory patients.
ISCHIAL DEFECT Seated position High recurrence rate 75%
about. Medially Based thigh flap Gluteus maximus
Myocutanuous flap V-Y pattern Biceps
femoris, semimembrenosis, semitendinosis
TFL flap.
SACRAL DEFECT.
Supine position Gluteus Maximus Muscle flap.
Either rotated, advanced or turn over
Transverse and vertical lumbosacral flap.
TROCHANTRIC DEFECT
Patients in lateral position esp. in hip flexion contracture.
Commonly used is TFL flap. Rotation results in T shaped junction between flap and closed donor site which is prone to dehiscence.
Others Options
For Multiple pressure sores and multiple previous procedures
No local options remaining. In extreme cases, Total Thigh flap
in which femur removed and thigh tissue for closure of wound.
Postoperative care
Continuation of preoperative care
Care full nursing care1. Positioning of patient ( not
lying on the surgical site )2. Special mattress
Nursing Care
1. Avoid maceration the wound2. Antibiotics Keep it clean & dry.
3. After 2 – 3 days transferred to an intermediate – level care facility.
Recurrence
95% recurrence rate Causes :1. Medical problems ( Diabetes,
smoking, cardiovascular disease )2. Nursing care ( turning, local
wound care, avoidance of urine & fecal contamination).