Pressure Ulcers

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					                                           Pressure Ulcers
Brandon Koretz MD
Michelle Eslami MD

       •   11-56% of new nursing home residents have a pressure sore
       •   incidence among ICU patients is 22-28.6 per 1000 pt days
       •   mortality for a NH resident with pressure sore is 2-6 times that of one without

 Stage***           Definition              Treatment Goals
 I                  Non-blanchable          Pressure Relief
                    Erythema, intact
 II                 Shallow ulcer           As above
                    involving dermis,       Keep tissue clean and moist
                    can be a blister
 III               Involves full             As above
                   thickness of              Remove devitalized and infected tissue
                   subcutaneous tissue;
                   may see tunneling
                   below skin surface
 IV                Extends beyond            As above
                   deep fascia into
                   tendon, bone,
                   muscle, or joint; may
                   see tunneling below
                   skin surface
*** If you can’t see the base of the ulcer, you can’t stage the ulcer.

External Risk Factors
    • Pressure, shear, friction, moisture, and chemical irritants
    • Pressure
                  Capillary filling pressure is about 32 mm Hg—when pressure between support surface and
                  bony prominence is higher, blood flow to skin stops ischemia, acidosis, toxin
                  accumulation, hemorrhage into interstitium (**non-blanchable erythema) necrosis and
                  cell death
                       Note: the number 32 mm Hg comes from studies conducted on human
                       cuticular arterioles; different tissues may tolerate different pressures.
                  Eventually, get decrease of intrinsic fibrinolysis and development of
                  intravascularcoagulation that further compromises perfusion even when pressure is

                    As pressure is more easily distributed in superficial tissue, the area closest to the bone will
                    sustain maximal damage. Also, muscle (deeper tissue) may be more vulnerable due to its
                    higher metabolic demand.
                    Can see evidence of tissue damage after 1-2 hours of pressures of 60 mm Hg—average
                    sacral pressure on standard hospital mattress is 100-150mm Hg
                    Likelihood of pressure sores is inversely related to frequency of repositioning
                    2 hours between repositioning is standard of care
    •    Friction
                    causes removal of stratum corneum (outermost layer of epidermis) and damage to
                    underlying, more delicate layers
                    can occur with moving patients because of friction of skin against bedding—USE
                    A DRAWSHEET!!
    •    Shear
                    occurs when friction holds skin in place but gravity pulls axial skeleton
                    down—results in stretching of perforating arterioles and compromise of perfusion of dermal
    •    Moisture
                    causes softening of stratum corneum which exacerbates the effects of friction

Intrinsic Risk Factors
     • age, immobility, incontinence, malnutrition, febrile illnesses, altered mental status, and
          decreased sensation are all associated with increased risk


Risk assessment
    • multiple scales but the key is think of them ahead of time

Pressure Reduction
    • turn every 2 hours (based on some animal and human trials), rotate by 30°
    • avoid pressure on the greater trochanter and lat malleolus—keep back at 30° to bed
    • float heels to prevent ulcers there
    • keep head of bed at lowest possible angel to minimize shear stress
    • it may be difficult to maintain every 2 hour position change—disrupts sleep cycle; can use low air loss
         matress or bed which turns patient automatically
    • no evidence for sheepskin or egg crate mattress covers
    • drawsheets and trapezes can reduce shear
    • **DO NOT USE DOUGHNUTS—tissue at center can still become ischemic

   • In-service educational programs (for nurses and nursing staff) have been shown to
        reduce incidence of pressure ulcers.

Pressure Relief
    • Low-air loss beds—allow for a controlled amount of air loss. Beds are waterproof but
         excess water is absorbed. Some type will pulsate and oscillate periodically to redistribute
    • Air-fluidized beds—actually are associated with high air loss. Patient floats on silicone
         coated glass beads that have heated air forced through them. Have little or no friction and
         decreased shear.

Debridement and Infection Control
   • `Mechanical
                Wet Dry dressings
                Hydrotherapy/Wound irrigation—35mL syringe with 19-G angiocath will produce

                   enough force to clean wound without driving bacteria deeper into tissue planes
    •    Sharp debridement
    •    Enzymatic debridement (e.g., Santyl, Granulex)
    •    Autolysis
    •    Antibiotics
                   Systemic use for osteomyelitis, cellulitis, or sepsis only
                   Local use may decrease microbial count—may be helpful if wound smells
    •    Chemical antiseptics
                   Limit use to 72 hours
                   Providone-iodine solution—has been shown to decrease bacteria count while not
                   slowing wound healing in one study.
                   Dakin’s solution (potassium hypochlorite), acetic acid, hydrogen peroxide, and
                   providone-iodine (Betadine) all inhibit fibroblasts growth in vitro.

Debridement of necrotic tissue
Wound Cleansing
Prevention and treatment of infection
Dressing Selection
    • Goal is to keep wound moist but surrounding skin dry
    • May require a ring of duoderm to cover intact skin and packing (wet to dry or
                   other packing) for the wound itself
    • Exact type of packing will depend on the wound itself—wounds with more
                   drainage may require a more absorbant packing (e.g., alginate)
    • Vitamin C—500 mg BID decreases surface area of pressure ulcer
    • Zn Sulfate—220 mg TID—may improve wound healing
    • General Nutrition

Cervo FA, Cruz AC, Posillico JA. Pressure ulcers analysis of guidelines for treatment and
    management. Geriatrics 2000; 55: 55-60.

Goode PS, Thomas DR. Pressure ulcers local wound care. Clinics in Geriatric Medicine 1997;
   13: 543-52.

Klitzman B, Kalinowski C, Glasofer SL, et al. Pressure ulcers and pressure relief surfaces. Clinics in
     Plastic Surgery 1998; 25: 443-50.

Patterson J, Bennett R. Prevention and treatment of pressure sores. JAGS 1995; 43: 919-27.


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