壓瘡

林明憲醫師臺北榮總高齡醫學中心國立陽明大學醫學系

105.08.07.

DefinitionDefinition Any lesion caused by unrelieved pressure

resulting in damage of underlying tissue Areas of local tissue trauma, usually

developing where soft tissues are compressedbetween bony prominences and any external surface for prolonged time periods

A sign of local tissue necrosis Most commonly found over bony

prominences subjected to external pressure Most common locations: sacrum, ischial

tuberosities, trochanters and heels— sacrum and heels most frequent

Synonymous terms — Pressure ulcer— Decubitus ulcer— Bedsore

EpidemiologyEpidemiology Prevalence Hospitalized elderly: 15% Patients expected to be bedridden or chair

bound > 1 week, ≥ stage II pressure ulcers: 28%

Prevalence varies by setting— Nursing home = 2.3% to 28%— Home care = 6% to 9%— Outpatient clinic = 1.6%

EpidemiologyEpidemiology

Incidence Incidence during hospitalization: 8~30% Timing: first 2 weeks of hospitalization

— The first 5 days in critical care unit

Highest incidence rate: orthopedic population (9-19%); quadriplegic (33-60%)

Morbidities associated with pressure ulcersMorbidities associated with pressure ulcers

Pain Disfigurement Septicemia Prolonged hospitalization Increased death rates quality issues

Morbidities associated with pressure ulcers-Pain

Morbidities associated with pressure ulcers-Pain

Pain—87% at dressing changes—84% at rest—42% both—18%: pain when CD, the highest level—Only 6% of them received analgesics—Stage III~IV > stage II pain? (some evidence)

Morbidities associated with pressure ulcers-Septicemia (I)

Morbidities associated with pressure ulcers-Septicemia (I)

Most severe complication Incidence 1.7/10,000 Overall mortality 48%: if pressure ulcer is the

source Transient bacteremia after debridement: 50% Infectious complication

—Wound infection—Cellulitis—Osteomyelitis

Morbidities associated with pressure ulcers-Septicemia (II)

Morbidities associated with pressure ulcers-Septicemia (II)

Among patients with nonhealing or worsening pressure ulcers—26% have underlying bone pathology, osteomyelitis—88% are colonized Pseudomonas aeruginosa—34% with Providencia species—Either pathogen should not be considered typical

colonization—Can be reservoirs for antibiotic-resistant bacteria

Morbidities associated with pressure ulcers-Death rateMorbidities associated with pressure ulcers-Death rate

Death rate among bed- or chair-bound patients—60% (PU+) vs 38% (PU-) 1 year after discharge

Nursing home resident whose pressure ulcers healed within 6 months or not—Mortality: 11%(PU healed) vs. 64%(PU not healed)

Mortality rate : 3.8 per 100,000 population—Marker for coexisting morbidity

Morbidities associated with pressure ulcers- Quality issue

Morbidities associated with pressure ulcers- Quality issue

Pressure ulcer incidence and severity are used as markers of quality care —long-term care facilities—home care agencies—acute care hospitals

Evaluate:—Each patient upon admission—Regularly thereafter for high risk group

PathophysiologyPathophysiology

Pressure ulcers are the result of mechanical injury to the skin and underlying tissues.

4 factors— Pressure— Shearing force— Friction— Moisture

PathophysiologyPathophysiology

PressurePressure

Perpendicular force or load exerted on a specific area, causing ishcemia and hypoxia of the tissues

Muscle and subcutaneous tissues are more sensitive than epidermis

High pressure area:— Supine: occiput, sacrum, heels— Sitting: ischial tuberosities— Sidelying: Trochanters

Pressure need to impair tissue perfusionPressure 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

Pressure under bony prominence, ex: — Buttock in lying position: 70mmHg— Sacrum and greater trochanter: 100-150mmHg— In seated persons, ischial tuberosities: 300mmHg

Factors lower the threshold— Repeated exposures to pressure— Loss of subcutaneous tissue

Shearing forcesShearing forces

Lower the amount of pressure required to cause damage to epidermis

Decrease the amount of pressure required to occlude blood vessels

Tangential forces, ex: sliding Important in development of deep tissue injury

Friction and MoistureFriction and Moisture

Friction— Cause intraepidermal blisters— Superficial erosions

Moisture— Directly lead to maceration and epidermal injury— Impact on friction forces

AssessmentAssessment

Risk assessment Assessment of pressure ulcer stage Assessment of pressure ulcer healing

Risk Assessment- FactorsRisk Assessment- Factors Immobility or severely restricted mobility being the

most important risk factors—>50 vs urine incontinence) Malnutrition Impaired mental status Altered sensation or response to pain and discomfort Increased body temperature Decreased blood pressure Advanced age

Risk Assessment - IntervalRisk Assessment - Interval

Acute care hospital: —Every 48Hrs

Home health setting: —Weekly for 4 weeks, followed by every other week

Nursing home resident: —Weekly for 4 weeks, followed by quarterly assessment

Risk Assessment – Tool (I)Risk Assessment – Tool (I)

Norton scale—Oldest, developed in 1961, in England—5 subscales: physical condition, mental state, activity,

mobility, incontinence, —Each scale 1-4, total score 5-20—≤16/20: onset of risk —≤12/20: high risk

Risk Assessment – Tool (II)Risk Assessment – Tool (II)

Braden scale— Developed in 1987, in USA— 6 subscale: sensory perception, moisture, activity,

mobility, nutrition, friction and shear— Each scale 1-4, except friction and shear 1-3— Total score 6-23— ≤16/23: at risk — 15-16/23: mild risk, 50~60% risk for stage I PU— 12-14/23: moderate risk, 65-90% risk for stage I or II PU —

1分 2分 3分 4分 分數感覺知覺程度（sensory

perception ）完全昏迷對疼痛沒有反應

昏迷但對疼痛有反應

清醒但部分感官受損

清醒正常

潮濕程度（moisture ） 皮膚持續潮濕

皮膚經常潮濕，更換中單/床單每天≦3次

皮膚偶爾潮濕，更換中單/床單

每天1次乾燥、乾淨

活動力（activity） 臥床不動 受限於輪椅

可偶爾下床行走

可經常下床行走

移動力（mobility）

完全無法自行翻身

大部分需他人協助翻身

少部分需他人協助翻身

可自行翻身

營養狀態（nutrition）

禁食或進食清流質5天以上

攝取熱量每天小於1200卡

維持管灌可滿足大部分需求

正常飲食滿足需求量

摩擦力/剪力（friction/shear） 有此問題 有潛在的問題 沒有明顯問題

總分 /23

註：分數≧16分（低危險）：每日皮膚評估一次。分數12~15分（中等危險）：皮膚評估＋每2小時翻身拍背一次。分數≦11分（高危險）： 皮膚評估＋每2小時翻身拍背一次＋氣墊床使用。

Braden壓瘡危險因子評估表

壓瘡風險評估工具之臨床效度壓瘡風險評估工具之臨床效度

評估工具＼

臨床效度

Braden量表

Norton量表

Gosnell量表

Waterlow量表

敏感度 88.0% 86.1% 46.3% 99.5%

特異性 75.1% 75.0% 90.9% 31.7%

橫斷式之調查法，在台灣地區北部、中部、南部及東部，各依人口分佈分層抽樣選取2,631住院病人為收案對象。

于博芮、李世代、林壽惠：台灣醫療院所壓瘡風險評估工具之臨床效度。台灣老年醫學雜誌 2005;1:79-88。

Assessment of Pressure Ulcer StageAssessment of Pressure Ulcer Stage

Grading or staging system based on observable depth of tissue destruction

Initial assessment: deepest layer of tissue involved

Mostly common used : —National Pressure Ulcer Advisory Panel’s (NPUAP)

classification system—(美國國家壓瘡諮詢委員會)

StagingStaging NPUAP (National Pressure Ulcer Advisory Panel) 2007 Stage I: Nonblanchable erythema

— Intact skin, usually over a bony prominence

Stage II: Partial thickness skin loss— Invulving epidermis and/or dermis

Stage III: Full thickness skin loss— Extend into subcutaneous tissues to deep fascia, but bone,

tendon, or muscle not exposed

Stage IV: Full thickness tissure loss— Exposed bone, tendon, or muscle

StagingStaging

Unstagable/Unclassified: Full thickness skin or tissue loss– depth unknown— Full-thickness injury— Actual depth obscured by slough and/or eschar— Cannot be staged until removed

Suspected Deep Tissue Injury– depth unknown— Purple 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 HealingAssessment of Pressure Ulcer Healing At a minimum:

—Location —Depth and Stage—Size —Wound bed description: necrotic tissue, exudate, wound edges for undermining and tunneling, presence or absence of granulation and epithelialization

Follow-up assessment: at least weekly Two research-based pressure ulcer assessment tools

—Bates-Jensen Wound Assessment Tool [BWAT]—NPUAP’s Pressure Ulcer Scale for Healingtool (PUSH)

Reduction in ulcer size over 1-2 week period predict healing outcome

Should improvement within 2-4 weeks If no evidence of ulcer improvement

— Consider changes in management strategy

Improvement for stage III and IV slower than II— Stage II: 75% healing in 60 days— Stage III or IV: 17% healing in 60 days

ManagementManagement

Local treatment Surgery Drugs Nutrition

Local treatmentLocal treatment

Debridement of necrotic tissue Adequate wound cleaning Application of appropriate topical therapy

DebridementDebridement Wound debridement:

—Reduce necrotic tissue burden—Decrease infection risk—Promote granulation tissue formation—NOT indicated for dry eschar on the heel or when the

pressure ulcer on an ischemic limb—5 methods of debridement: clinician preference, avalibility

Surgical or sharp debridement for extensive necrosis or when obtaining a clean wound bed quickly is important

More conservative methods (autolytic and enzymatic) for those in long-term care or home care environments

Adequate wound debridement is essential to wound bed preparation and healing.

Surgical debridementSurgical debridement

use of a scalpel, scissors, or other sharp instruments to remove nonviable tissue.

most rapid form of debridement indicated over other methods

—for removing thick, adherent, and/or large amounts of nonviable tissue

—when advancing cellulitis or signs of sepsis

Mechanical debridementMechanical debridement

Use of wet-to-dry dressings, whirlpool, lavage, or wound irrigation.

Wet-to-dry gauze dressings continue to be used for debridement

Disadvantages: —increased time/labor for application/removal of the dressings, —removing viable tissue as well as nonviable tissue —pain

Used cautiously, can traumatize new granulation tissue and epithelial tissue

Adequate analgesia should be administered

Enzymatic debridementEnzymatic debridement

Applying a concentrated, commercially preparedenzyme to the surface of the necrotic tissue

aggressively degrade necrosis by digesting devitalized tissue

3 commercially enzymes in USA: collagenase, papain-urea, and papain-urea with chorophyllin

Some of the effects attributed to autolysis Debridement faster than with autolysis More conservative than sharp debridement

Autolytic debridementAutolytic debridement Using the body’s 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 tissues

May be slower to achieve a clean ulcer bed than other methods.

BiosurgeryBiosurgery

The application of maggots (disinfected fly larvae, Phaenicia sericata) to the wound

Typically at a density of 5 to 8 per cm2

May not be acceptable to all patients May not be available in all areas

Adequate wound cleaningAdequate wound cleaning General rule Pressure ulcer cleaning at changing dressing If 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 used

For clean wounds, less force and physiologic solutions such as normal saline should be used.

Should not use on clean pressure ulcers :— Povidone-iodine— Iodophor (易多碘)— Sodium hypochlorite (次氯酸鈉)— Hydrogen peroxide (H2O2)— Acetic acid

Toxic to fibroblast and impair wound healing

Topical therapyTopical therapy

Using moist wound healing dressings Moist wound healing allows wounds to re-

epithelialize up to 40% faster than wounds left open to air

These dressings are changed every 3 to 5 days, which allows wound fluid to gather underneath the dressing, facilitating epithelial migration

敷料種類敷料種類類別 舉例

Gauze dressing (紗布) 紗布Transparent films dressing (透明薄膜) Opisite, TegadermHydrogel (親水凝膠) DuoDerm gelHydrocolloid dressing (親水膠體敷料) DuoDermAlginate dressing (藻酸鹽敷料) Kaltostat, SeasorbHydrofiber dressing (親水纖維敷料) Aquacel, Aquacel AgFoams dressing (海綿型敷料) PU泡棉, PVA泡棉Composites dressing (複合性敷料)

Surgery Surgery

Primary closure A variety of approaches to skin graft and

myocutaneous flap Removal of underlying bony prominence Large infected pressure ulcers: more aggressive

procedures ex amputation sometimes required

Drugs - AntibioticDrugs - Antibiotic Antibiotics

—Antibiotics may be systemic or local Systemic antibiotics:

—S/S of systemic infection, sepsis or cellulitis with fever and elevated WBC

—Osteomyelitis—Prevention of bacterial endocarditis in patients

with valvular heart disease—Who require debridement of pressure ulcer

Broad-spectrum coverage—GNB, GPC, anaerobes

Drugs - AntibioticDrugs - Antibiotic Appropriate choices for antibiotic therapy

— Unasyn— Imipenem— Meropenem— Timentin— Tazocin— Combination of clindamycin or metronidazole with

ciprofloxacin, levofloxacin, or aminoglycosides— Vancomycin for MRSA

Drugs - AntibioticDrugs - Antibiotic

The most effective strategy for preventing infection and dealing with existing infection is adequate debridement of necrotic tissue

In patients with S/S of systemic infection and sepsis, the appropriate debridement method is surgical debridement.

Drugs - AntibioticDrugs - Antibiotic

Topical antibiotics (silver sulfadiazine):— For stage III or IV ulcers with evidence of local infection— For clean pressure ulcer not healing after 2-4 weeks of

optimal management

Prolonged silver release topical dressings: effective in MRSA colonization

Drugs - PainDrugs - Pain

Limited evidence to guide clinician Pressure ulcer alone: may not require routine pain

medication Medication prior to procedures is essential Opioids and/or NSAIDs 30 minutes prior to the

procedure Topical anesthetics or topical opioids

NutritionNutrition Difficult to define a causal relationship between

malnutrition and pressure ulcer development Some 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/d 1.25 to 1.5 g/kg/d of protein

NutritionNutrition

Nutritional supplementation by tube-feeding to persons with pressure ulcers: not positive results

No evidence exists for use of supplemental vitaminsor minerals (e.g., vitamin A, E, C, zinc) in persons with pressure ulcers, except for deficiency

Persons with pressure ulcer or at risk + malnutrition: Nutritional assessment, nutrition support as indicated

Glutamine, Arginine, HMB

PreventionPrevention Scheduled turning and repositioning programs Pressure reduce/relieve support surfaces General skin care Nutritional support

Scheduled turning and repositioning programsScheduled turning and repositioning programs Patient at risk, unable to move independently Time interval: every 2 Hrs Avoid pressure on bony prominence, esp malleolus,

trochanter: 30-degree side-lying instead of 90-degree side lying

Maintain head of bed at lowest degree of elevation: decrease sacral area exposure to shearing force

Techniques: Turning sheets, draw sheets, pillows

Pressure reduce/relieve support surfaces Pressure reduce/relieve support surfaces

Static— Foam, gel, static air, water, combination— Less expensive

Dynamic— Alternating air(間歇式氣墊), low-air-loss(低壓氣浮

床墊), or air-fluidized(矽砂床)— 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 support

— Adverse effects: dehydration, sensory deprivation, loss of muscle strength, difficulty with mobilization

Pressure reduce/relieve support surfacesPressure reduce/relieve support surfaces

May reduce frequency of repositioning required in some paitents

Relative reduction in incidence of 60%

General skin careGeneral skin care Skin inspection

— Daily, esp attention to bony prominence— Reddened areas should not be massaged

Incontinence assessment and management Skin hygiene intervention

ReferenceReference

Hazzard’s 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/