103.09.13.

DefinitionAny lesion caused by unrelieved pressure resulting in damage of underlying tissueAreas of local tissue trauma, usually developing where soft tissues are compressed between bony prominences and any external surface for prolonged time periods

A sign of local tissue necrosisMost commonly found over bony prominences subjected to external pressureMost common locations: sacrum, ischial tuberosities, trochanters and heels sacrum and heels most frequentSynonymous terms Pressure ulcerDecubitus ulcerBedsore

EpidemiologyPrevalenceHospitalized elderly: 15%Patients expected to be bedridden or chair bound > 1 week, stage II pressure ulcers: 28%Prevalence varies by settingNursing home = 2.3% to 28%Home care = 6% to 9%Outpatient clinic = 1.6%

EpidemiologyIncidenceIncidence during hospitalization: 8~30%Timing: first 2 weeks of hospitalization The first 5 days in critical care unitHighest incidence rate: orthopedic population (9-19%); quadriplegic (33-60%)

Morbidities associated with pressure ulcersPain DisfigurementSepticemiaProlonged hospitalizationIncreased death ratesquality issues

Morbidities associated with pressure ulcers- PainPain87% at dressing changes84% at rest42% both18%: pain when CD, the highest levelOnly 6% of them received analgesicsStage III~IV > stage II pain? (some evidence)

Morbidities associated with pressure ulcers- Septicemia (I)Most severe complicationIncidence 1.7/10,000Overall mortality 48%: if pressure ulcer is the sourceTransient bacteremia after debridement: 50%Infectious complicationWound infectionCellulitisOsteomyelitis

Morbidities associated with pressure ulcers- Septicemia (II)Among patients with nonhealing or worsening pressure ulcers26% have underlying bone pathology, osteomyelitis88% are colonized Pseudomonas aeruginosa34% with Providencia speciesEither pathogen should not be considered typical colonizationCan be reservoirs for antibiotic-resistant bacteria

Morbidities associated with pressure ulcers- Death rateDeath rate among bed- or chair-bound patients60% (PU+) vs 38% (PU-) 1 year after dischargeNursing home resident whose pressure ulcers healed within 6 months or notMortality: 11%(PU healed) vs. 64%(PU not healed)Mortality rate : 3.8 per 100,000 populationMarker for coexisting morbidity

Morbidities associated with pressure ulcers- Quality issuePressure ulcer incidence and severity are used as markers of quality care long-term care facilitieshome care agenciesacute care hospitalsEvaluate:Each patient upon admissionRegularly thereafter for high risk group

PathophysiologyPressure ulcers are the result of mechanical injury to the skin and underlying tissues.4 factorsPressureShearing forceFrictionMoisture

Pathophysiology

PressurePerpendicular force or load exerted on a specific area, causing ishcemia and hypoxia of the tissuesMuscle and subcutaneous tissues are more sensitive than epidermisHigh pressure area:Supine: occiput, sacrum, heelsSitting: ischial tuberositiesSidelying: Trochanters

Pressure need to impair tissue perfusion Closing pressures Arteriole - 32 mm Hg Venule - 15 mm Hg Capillary pressure - 25 mm Hg > 32 mmHg pressure would cause tissue ischemia

PressurePressure under bony prominence, ex: Buttock in lying position: 70mmHgSacrum and greater trochanter: 100-150mmHgIn seated persons, ischial tuberosities: 300mmHgFactors lower the thresholdRepeated exposures to pressureLoss of subcutaneous tissue

Shearing forcesLower the amount of pressure required to cause damage to epidermisDecrease the amount of pressure required to occlude blood vesselsTangential forces, ex: slidingImportant in development of deep tissue injury

Friction and MoistureFrictionCause intraepidermal blistersSuperficial erosionsMoistureDirectly lead to maceration and epidermal injuryImpact on friction forces

AssessmentRisk assessmentAssessment of pressure ulcer stageAssessment of pressure ulcer healing

Risk Assessment- FactorsImmobility or severely restricted mobility being the most important risk factors>50 vs urine incontinence) MalnutritionImpaired mental statusAltered sensation or response to pain and discomfortIncreased body temperatureDecreased blood pressureAdvanced age

Risk Assessment - IntervalAcute care hospital: Every 48HrsHome health setting: Weekly for 4 weeks, followed by every other weekNursing home resident: Weekly for 4 weeks, followed by quarterly assessment

Risk Assessment Tool (I)Norton scaleOldest, developed in 1961, in England5 subscales: physical condition, mental state, activity, mobility, incontinence, Each scale 1-4, total score 5-2016/20: onset of risk 12/20: high risk

Risk Assessment Tool (II)Braden scaleDeveloped in 1987, in USA6 subscale: sensory perception, moisture, activity, mobility, nutrition, friction and shearEach scale 1-4, except friction and shear 1-3Total score 6-2316/23: at risk 15-16/23: mild risk, 50~60% risk for stage I PU12-14/23: moderate risk, 65-90% risk for stage I or II PU

16 12~15 2 11 2 Braden

1234 sensory perception moisture /3/1activitymobilitynutrition51200/friction/shear /23

2,631 2005;1:79-88

BradenNortonGosnellWaterlow88.0%86.1%46.3%99.5%75.1%75.0%90.9%31.7%

Assessment of Pressure Ulcer StageGrading or staging system based on observable depth of tissue destructionInitial assessment: deepest layer of tissue involvedMostly common used : National Pressure Ulcer Advisory Panels (NPUAP) classification system()

StagingNPUAP (National Pressure Ulcer Advisory Panel) 2007Stage I: Nonblanchable erythema Intact skin, usually over a bony prominenceStage II: Partial thickness skin lossInvulving epidermis and/or dermisStage III: Full thickness skin lossExtend into subcutaneous tissues to deep fascia, but bone, tendon, or muscle not exposedStage IV: Full thickness tissure lossExposed bone, tendon, or muscle

StagingUnstagable/Unclassified: Full thickness skin or tissue loss depth unknownFull-thickness injuryActual depth obscured by slough and/or escharCannot be staged until removedSuspected Deep Tissue Injury depth unknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear

Assessment of Pressure Ulcer HealingAt a minimum: Location Depth and StageSize Wound bed description: necrotic tissue, exudate, wound edges for undermining and tunneling, presence or absence of granulation and epithelializationFollow-up assessment: at least weeklyTwo research-based pressure ulcer assessment toolsBates-Jensen Wound Assessment Tool [BWAT]NPUAPs Pressure Ulcer Scale for Healingtool (PUSH)

Reduction in ulcer size over 1-2 week period predict healing outcomeShould improvement within 2-4 weeksIf no evidence of ulcer improvement Consider changes in management strategyImprovement for stage III and IV slower than IIStage II: 75% healing in 60 daysStage III or IV: 17% healing in 60 days

ManagementLocal treatmentSurgeryDrugsNutrition

Local treatmentDebridement of necrotic tissueAdequate wound cleaningApplication of appropriate topical therapy

DebridementWound debridement:Reduce necrotic tissue burdenDecrease infection riskPromote granulation tissue formationNOT indicated for dry eschar on the heel or when the pressure ulcer on an ischemic limb5 methods of debridement: clinician preference, avalibilitySurgical or sharp debridement for extensive necrosis or when obtaining a clean wound bed quickly is importantMore conservative methods (autolytic and enzymatic) for those in long-term care or home care environmentsAdequate wound debridement is essential to wound bed preparation and healing.

Surgical debridementuse of a scalpel, scissors, or other sharp instruments to remove nonviable tissue. most rapid form of debridementindicated over other methods for removing thick, adherent, and/or large amounts of nonviable tissue when advancing cellulitis or signs of sepsis

Mechanical debridementUse of wet-to-dry dressings, whirlpool, lavage, or wound irrigation. Wet-to-dry gauze dressings continue to be used for debridementDisadvantages: increased time/labor for application/removal of the dressings, removing viable tissue as well as nonviable tissue painUsed cautiously, can traumatize new granulation tissue and epithelial tissueAdequate analgesia should be administered

Enzymatic debridementApplying a concentrated, commercially prepared enzyme to the surface of the necrotic tissueaggressively degrade necrosis by digesting devitalized tissue3 commercially enzymes in USA: collagenase, papain-urea, and papain-urea with chorophyllinSome of the effects attributed to autolysisDebridement faster than with autolysisMore conservative than sharp debridement

Autolytic debridementUsing the bodys own mechanisms to remove nonviable tissue. Maintaining a moist wound environment allows collection of fluid at the wound site, which allows enzymes within the wound fluid to digest necrotic tissue. Adequate wound cleansing to wash out the partially degraded nonviable tissue. More effective than wet-to-dry gauze dressings, selectively removes only necrotic tissue protects healthy tissuesMay be slower to achieve a clean ulcer bed than other methods.

BiosurgeryThe application of maggots (disinfected fly larvae, Phaenicia sericata) to the wound Typically at a density of 5 to 8 per cm2May not be acceptable to all patientsMay not be available in all areas

Adequate wound cleaningGeneral rulePressure ulcer cleaning at changing dressingIf an ulcer contains necrotic debris or is infected, then antimicrobial activity is more important. For wounds with large amounts of debris, more vigorous mechanical force and stronger solutions may be usedFor clean wounds, less force and physiologic solutions such as normal saline should be used.

Should not use on clean pressure ulcers :Povidone-iodineIodophor ()Sodium hypochlorite ()Hydrogen peroxide (H2O2)Acetic acidToxic to fibroblast and impair wound healing

Topical therapyUsing moist wound healing dressingsMoist wound healing allows wounds to re-epithelialize up to 40% faster than wounds left open to airThese dressings are changed every 3 to 5 days, which allows wound fluid to gather underneath the dressing, facilitating epithelial migration

Gauze dressing ()Transparent films dressing ()Opisite, TegadermHydrogel ()DuoDerm gelHydrocolloid dressing ()DuoDermAlginate dressing ()Kaltostat, SeasorbHydrofiber dressing ()Aquacel, Aquacel AgFoams dressing ()PU, PVAComposites dressing ()

Surgery Primary closureA variety of approaches to skin graft and myocutaneous flapRemoval of underlying bony prominenceLarge infected pressure ulcers: more aggressive procedures ex amputation sometimes required

Drugs - AntibioticAntibioticsAntibiotics may be systemic or localSystemic antibiotics: S/S of systemic infection, sepsis or cellulitis with fever and elevated WBC OsteomyelitisPrevention of bacterial endocarditis in patients with valvular heart diseaseWho require debridement of pressure ulcerBroad-spectrum coverageGNB, GPC, anaerobes

Drugs - AntibioticAppropriate choices for antibiotic therapyUnasynImipenemMeropenemTimentinTazocinCombination of clindamycin or metronidazole with ciprofloxacin, levofloxacin, or aminoglycosidesVancomycin for MRSA

Drugs - AntibioticThe most effective strategy for preventing infection and dealing with existing infection is adequate debridement of necrotic tissueIn patients with S/S of systemic infection and sepsis, the appropriate debridement method is surgical debridement.

Drugs - AntibioticTopical antibiotics (silver sulfadiazine):For stage III or IV ulcers with evidence of local infectionFor clean pressure ulcer not healing after 2-4 weeks of optimal managementProlonged silver release topical dressings: effective in MRSA colonization

Drugs - PainLimited evidence to guide clinicianPressure ulcer alone: may not require routine pain medicationMedication prior to procedures is essentialOpioids and/or NSAIDs 30 minutes prior to the procedureTopical anesthetics or topical opioids

NutritionDifficult to define a causal relationship between malnutrition and pressure ulcer developmentSome evidence: nutritional support to persons at risk for pressure ulcers with relative reduction in pressure ulcer incidence of 25%Some evidence: high-protein nutritional supplements (24-25% protein) improves pressure ulcer healing 30 to 35 kcal/kg/d1.25 to 1.5 g/kg/d of protein

NutritionNutritional supplementation by tube-feeding to persons with pressure ulcers: not positive resultsNo evidence exists for use of supplemental vitamins or minerals (e.g., vitamin A, E, C, zinc) in persons with pressure ulcers, except for deficiencyPersons with pressure ulcer or at risk + malnutrition: Nutritional assessment, nutrition support as indicatedGlutamine, Arginine, HMB

PreventionScheduled turning and repositioning programsPressure reduce/relieve support surfaces General skin careNutritional support

Scheduled turning and repositioning programsPatient at risk, unable to move independentlyTime interval: every 2 HrsAvoid pressure on bony prominence, esp malleolus, trochanter: 30-degree side-lying instead of 90-degree side lyingMaintain head of bed at lowest degree of elevation: decrease sacral area exposure to shearing forceTechniques: Turning sheets, draw sheets, pillows

Pressure reduce/relieve support surfaces StaticFoam, gel, static air, water, combinationLess expensiveDynamicAlternating air(), low-air-loss(), or air-fluidized()Use if the status surface is compressed to < 1 inch or high-risk patient has reactive hyperemia on a bony prominence despite use of static supportAdverse effects: dehydration, sensory deprivation, loss of muscle strength, difficulty with mobilization

Pressure reduce/relieve support surfacesMay reduce frequency of repositioning required in some paitentsRelative reduction in incidence of 60%

General skin careSkin inspectionDaily, esp attention to bony prominenceReddened areas should not be massagedIncontinence assessment and managementSkin hygiene intervention

ReferenceHazzards Geriatric Medicine and Gerontology, 6th ed. New York: Mc Graw Hill, 2009:703-715 Textbook of Geriatric Medicine International, Souel: Argos, 2010:411-418 NPUAP (National Pressure Ulcer Advisory Panel): http://www.npuap.org/

*Pressure ulcer preferred, pressure is the main factorNot only lying down, sitting also cause damageThese 2 factors are especially important in superficial lesionsDiscoloration of skin, warmth, edema, induration maybe indications in persons with darker skin: *