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Pressure ulcers


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Overview of Pressure Ulcers

Published in: Health & Medicine

Pressure ulcers

  1. 1. Pressure UlcersMarc Evans M. Abat,MD, FPCP, FPCGM Internal Medicine- Geriatric Medicine
  2. 2. Definition• Any lesion caused by unrelieved pressure leading damage of underlying tissue – Synonymous to decubitus ulcer and bedsores but the above term denotes the primary pathophysiologic factor
  3. 3. Staging• Stage I – Nonblanchable erythema of intact skin; may also be other discoloration, warmth, edema and induration – 10-fold increase in risk of developing higher-staged ulcers
  4. 4. • Stage II – Partial-thickness skin loss involving the epidermis or also the dermis• Stage III – Extend to the subcutaneous tissues and deep fascia – Typically show undermining• Stage IV – Involve muscle and bone
  5. 5. Stage I Stage IIStage III Stage IV
  6. 6. • Eschar formation – Full-thickness injury – Has to be removed prior to staging• Pressure-related blister formation – Cannot be staged clinically
  7. 7. Epidemiology• Acute care setting – Stage II and higher prevalence 3-11%, incidence 1-3% – After 1 week of confinement, incidence 28%, prevalence 8-30% – >50% occur in patients >70 years old
  8. 8. • In nursing homes – Prevalence of 20-33% and incidence of 11- 14%• Sepsis – Most serious complication of pressure ulcers – In-house mortality of 60% when the ulcer is the source of bacteremia
  9. 9. • Infected pressure ulcers – Most common infection in skilled nursing facilities (6% of residents)• Osteomyelitis – In 26% of non-healing pressure ulcers
  10. 10. • Associated with prolonged and expensive hospitalizations• Associated with pain – 59-85% of those who can communicated describe pain – 45% report ulcer pain as “horrible”
  11. 11. • Increased mortality – 60% at 1 year after discharged for those who develop a pressure ulcer
  12. 12. Pathophysiology• 4 factors implicated: pressure, shearing forces, friction and moisture• Muscle and subcutaneous tissuemore sensitive to pressure injury
  13. 13. • Pressure on bony prominences – 100-150 mmHg on regular mattress while lying down – 300 mmHg on ischial tuberosities while sitting – Enough to decrease transcutaneous oxygen tension to 0• Other factors may lower the time or pressure needed to cause full-thickness injuries
  14. 14. • Shearing forces-tangential forces on the skin when the patient slides while sitting or lying down in an elevated position – Lowers the pressure needed to cause ulcers• Friction leads to intraepidermal blistersunroofed, leading to superficial erosions• Moisturemay lead to maceration
  15. 15. • Effect of pressure – Ischemia and accumulation of cellular toxins – Damage begins in deeper tissues – Persistent pressurevascular leakage and interstitial edemaeventual hemorrhage (stage I)• Superimposed bacterial infection (both deep and superficial)
  16. 16. Presentation• Any disease that leads to immobility predisposes to pressure ulcers• Risk factors other than immobility – Incontinence (particularly fecal) – Nutritional factors (decreased lymphocyte count, hypoalbuminemia, inadequate intake, decreased body weight, depleted triceps skin fold)
  17. 17. • Other factors – Dry skin – Increased body temperature – Decreased blood pressure – Age – Age-related skin changes
  18. 18. Assessment• Includes assessment of risk factors, including nutritional assessment• Location, size, stage and wound characteristics of ulcer at onset – Includes assessment of tracts, undermining, tunneling, exudate, necrotic tissue, granulation and epithelialization
  19. 19. • Follow-up assessment using above parameters at least weekly – PUSH score – Decrease in ulcer size over 2 weeks usually predicts healing• Sinograms to assess tract extent• Cultures using needle aspiration or biopsy speciments; may include bone biopsys – Culture of swabs not helpful as bacterial colonization in eventual – Important if ulcer does not heal after 4 weeks or if with obvious infection
  20. 20. • Osteomyelitis diagnosis may be difficult due to similarity of pressure-induced bone changes – Presence of abnormal plain radiograph, WBC count of 15,000 and ESR >120 mm has probability of osteomyelitis of 70%
  21. 21. • Most common bacterial isolates – Gram (-) aerobic rods (45% of isolates) – Gram (+) aerobic cocci (39%) – Bacteroides species, most common anaerobic isolate
  22. 22. ManagementPharmacologic• Vitamin and mineral supplementation for those with deficiencies• Systemic antibiotics indicated for patients with – Sepsis – Cellulitis – Osteomyelitis – Prevention of bacterial endocarditis in those with VHD and requiring debridement
  23. 23. • Broad spectrum antibiotics for those with suspected bacteremia, pending culture results – Ampi-sulbactam – Carbapenems – Pip-tazo – Clindamycin/metronidazole + quinolones
  24. 24. • Vancomycin for methicillin-resistent Staphylococcus aureus• Deeper ulcers may have some benefit for topical antibiotics – Silver sulfadiazine x 2 weeks – Avoid iodophors, sodium hypochlorite or acetic acid (toxic to fibroblast)
  25. 25. Nonpharmacologic• Adequate dietary, especially protein intake – Target 30-35 kcal/kg BW/day with 1.25- 1.50 g CHON/kg BW – May use alternative feeding methods if oral intake is inadequate – Vitamin and mineral supplementation
  26. 26. • Use of pressure-relieving devices – Regular air/foam mattresses – Egg-crate foam mattresses – Static mattresses (should not bottom out and provide at least 2.5 cm of support) • Usually appropriate for those who can still assume different positions – Dynamic mattresses • Air-fluidized mattresses • Low-air loss mattresses
  27. 27. • Debridement – Sharp debridement – Mechanical approaches (wet-to-dry dressing, irrigation, hydrotherapy) • Irrigation pressure 4-15 psi using a 30-cc syringe with a 18G needle – Enzymatic approaches (collagenases) – Autolytic approaches (contraindicated in infected ulcers)
  28. 28. • Occlusive dressings for clean wound – Not proven to me more effective for stage III or IV ulcers but reduces the nursing time needed• Moist gauze dressing using normal saline for the ulcer base• The aim of dressing the ulcer is to maintain a moist environment for would healing and autolytic debridement
  29. 29. • Skin sealants – Prevents friction and protects from adhesives – Contains alcohol and should not be used under most hydrocolloids
  30. 30. • Impregnated gauze – Gauze impregnated with saline or other substances – Make sure that impregnating substance is not harmful to wound healing – Limited absorbent capacity
  31. 31. • Composite dressings – Combination of different dressing groups – Properties depend on the components
  32. 32. • Transparent film dressing – Polyurethane and polyethylene membrane coated with a layer of acrylic, hypoallergenic adhesive – Promotes epithelialization, moist wound healing – Bacterial barrier, autolysis – May reinjure wound on removal – Can lead to wound edge maceration – Not for wounds with moderate to heavy exudation
  33. 33. • Hydrocolloid – Gelatin or carboxymethycellulose in a polyisobutylene adhesive base – Moist would healing with absorption of light to moderate wound fluid – Increased wear time – Reduces pain, promotes autolysis – Not for those withg heavy exudate – Odor on removal – Limited absorption
  34. 34. • Hydrogels – May or may not have supporting fabric net – High water content with varying gel forming material – Moist wound healing with low to moderate drainage – Promotes autolysis – Reduces pain and rehydrates dry wounds; cooling effect – Does not cause reinjury on removal – Can dry out or may macerate surrounding tissues – Candidiasis may occur with inappropriate use
  35. 35. • Wound fillers – Made of copolymer starch or dextranomer beads which absorb wound fluid to form a gel – Moderate to large absorption and fills up dead space – Moisture retentive and promotes autolysis – Requires another dressing to hold it in – May have an odor – Requires wound irrigation to remove
  36. 36. • Enzyme debriding agent – Can debride necrotic tissue – Hard eschar chould be removed first – Discontinued when granulation appears – Require secondary dressing – May be inhibited by irrigation solutions
  37. 37. • Alginates – Calcium or sodium salts of alginic acid – Moisture retentive and promotes autolysis – Moderate to large moisture absorption – Reduces pain and can fill dead space – Should not be used in low-exudate wounds and may dry out
  38. 38. • Lubricating agents – Promotes moist wound healing – Limited autolysis – Reduces pain – Requires secondary dressing – Non-absorptive – May be used to impregnate gauze
  39. 39. • Foams – Hydrophilic and non- adherent modified polyurethane foam – In wafers, pillows; with film covers – Surfactant impregnated or with a charcoal layer – Moderate to large absorption – Moist wound healing – Can be used with topical medications and infected wounds – Requires taping
  40. 40. • Collagen – Bovine collagen attached to nylon mesh, or powder or paste – Also comes in 90% collagen and 10% alginate – Absorbs small to moderate exudate – Non-adherent – For contaminated, infecteed wounds – Can be used with topical agents – Requires secondary dressing – Sensitivity to bovine material
  41. 41. • Surgical correction (attempted only in clean wounds) – Primary closure – Skin grafting – Myocutaneous flaps • 30% complication rate • Complications included necrosis, dehiscence, flap infection, hematoma • 70% healing rate by time of discharge – Removal of underlying bony prominences
  42. 42. • Other modalities – Hyperbaric oxygen therapy • Effects not statistically significant – Growth factors • For ulcers that do not heal with a comprehensive approach – Larvae therapy – Vacuum-assisted closure • Reduces bacterial load and improves perfusion and granulation – Electrical stimulation • Improves healing in small trials; dose and type of wound to be applied with not yet determined
  43. 43. Prevention• Systematic risks assessment – Braden scale • A score of 18 or less in any patient indicates risk for pressure ulceration – Norton scale
  44. 44. • Appropriate skin care – Systematic skin inspection – Skin cleaning with mild cleansing agent at time of soiling and at regular intervals – Minimize skin dryinguse moisturizers – Minimize excessive moisture – Minimize friction and shear forces – Ensure adequate dietary intake
  45. 45. • Frequent repositioning every 2 hours for supine patients – The back should be at a 30° angle with the support surface; avoid a 90° angle – Minimize head elevation to compelling indications like postfeeding or if in respiratory distress• If patient needs to be seated, should not be for more than 1 hour; positions are shifted every 15- 30 minutes – May use pillows behind the knees, back or neck to provide more support – Avoid doughnut rings (increases venous congestion)
  46. 46. • Off-loading devices of extremities in the supine or seated position• Sheepskin and foam egg crate mattress (or other foam overlays) – Inexpensive but do not have the capability of reducing pressure enough to reduce injury• Use of pressure-relieving mattresses – 60% reduction in incidence of pressure ulcers
  47. 47. • Treatment of infections distant from clean pressure ulcers – Bacteremia from distant infections may seed in the clean ulcer due to least resistance