Management of pressure ulcers

MS SHAWALTUL AKHMA BT HARUN NOR RASHID

PLASTIC SURGEON

HOSPITAL RAJA PEREMPUAN ZAINAB II, KOTA BHARU

KELANTAN

INTRODUCTION

P

ressure sore/ bed sore/ decubitus ulcer used interchangeably.

B

edsore / decubitus (latin – to lie down) ulcer should be avoided.

D

efinition – soft tissue injuries resulting from unrelieved pressure over

bony prominence.

R

elieving the pressure – key to healing and prevention.

P

oor nutrition, incontinence with persistent soilage and

moisture, dementia, paralysis, friction, and shear make

healing less likely.

M

ultidisciplinary approach - orthopedic surgery, internal

medicine, mental health care, plastic surgery, nutritionist

and rehabilitation.

staging

T

he presence of eschar

obscures the severity of

the underlying injury,

thereby making

preoperative staging

inaccurate

Unstageable

Stage 1 & 2

Stage 3 & 4

epidemiology

A

pproximately 9% of all hospitalized patients develop

pressure sores.

Age, male gender, impaired sensory perception, moisture,

immobility, poor nutrition, and friction/shear as risk factors.

p

ressure sore location 96% occur below the level of the umbilicus

7

5% of all pressure sores

are located around the

pelvic girdle.

location

pathophysiology

C

ompression > ischemia (if not relieved) > necrosis > ulcer.

I

f the external compressive force exceeds capillary bed

pressure (12 mm Hg on the venous end to 32 mm Hg on the

arterial end) capillary perfusion is impaired and ischemia

will ensue.

Relationship between pressure and time.

pathophysiology

prevention

P

atients who are at risk of developing pressure sores—

and their families and caregivers—must be informed

and educated about proper pressure ulcer prevention.

S

kin Moisture. Excessive skin moisture lead to

ulceration. Keep clean and dry.

prevention

P

ressure Dispersion - air mattresses or mattress composed of high

density foam-, gel-, water-, or air-filled sacs

The goal of the pressure-relief surface is to diffuse the pressure

overlying the bony prominences to the surrounding areas.

M

attress overlays - alternating pressure mattresses, also known as

alternating air cell (AAC) mattresses. Alternates inflation and deflation

of cells to constantly change pressure points and promote circulation.

ALTERNATING PRESSURE MATTRESS

Pressure dispersion

Medical management

N

onsurgical resolution - patient idiosyncrasies and

quality of nursing care.

D

ressing and ointment.

D

ressing material selection depend on wound condition.

Modern dressing material

I

mpregnated gauze Hydrofibre

H

ydrocolloids Antibacterial

H

ydrogel VAC

A

lginate

F

oam

Foam dressing

Preoperative care

H

olistic approach – more than addressing the wound.

Systemic and local care.

S

ystemic – nutritional, treatment of anaemia, relief of spasm,

pressure, psychological status.

L

ocal – aimed at securing a surgically clean wound.

Surgical treatmentE

xcision of the ulcer, surrounding scar and soft-tissue

calcification, if any

R

adical removal of underlying bone.

P

adding of bone stumps and filling dead space with fascia

or muscle flaps.

G

rafting the donor site of the flap with split skin, if

applicable.

Excision of the ulcer, surrounding scar and soft-tissue calcification

Radical removal of underlying bone

padding of bone stumps and filling dead space with flaps.

GraFting the donor site

Flap options

Flaps for closure of the sacrum

Flap for trochanteric sore

Postoperative care

N

utrition, medical (for spasm, diabetes, hypertension), psycho-

logical, and rehabilitative care continues as required.

T

he patients are positioned to avoid pressure on the operative

site, with turning every 2 hours, and use of low-air-loss

mattresses when available.

Postoperative care

T

he control of urine and stool is important and in

the most difficult cases colostomies are required.

A

ntibiotic and drains.

R

ecurrence is high.