Decubitus ulcer

decubitus ulcer and its management

1. Decubitus Ulcer and Its management Presenter- Dr. Binaya kumar Padhi PGT, Department of General surgery HMCH, Bhubaneswar

2. Definition Decubitus ulcer is a representative of traumatic ulcer due to direct pressure on bony tissues or shearing forces resulting in micro vascular compromise, leading to tissue necrosis and ulceration In Latin “decumbere” means “to lie down ’’ and decubitus is the posture adopted by a person who is lying down Synonym- Bed sores Trophic ulcer Ischemic ulcer Necrotic ulcer The most preferred term is ‘pressure sores’ because it best suggests the true cause of these lesions

3. History 1853- Brown- Sequard - identified pressure and moisture as the major cause of ulceration. 1873-Paget- Defined pressure sores as the sloughing and death of a part produced by the pressure 1879-Charcot’s theory-stated that nerve injury causes the release of a neurotrophic factor that resulted in tissue necrosis. 1940-Munro-spinal cord injury caused a disturbance of the ANS resulted in a decrease of the peripheral reflexes and predisposed to skin ulcerataion . For this reason ,he considered pressure sores as an inevitable complication of SCI

4. Epidemiology Pressure sores are common conditions among patients hospitalised in acute and chronic care facilities. Common among hospitalised and accounts for 3-10% of hospitalised patients Prevalence rate as high as 25-33% in SCI It is most common around the hips (70%) Lower extremities (15-25%)

5. Risk factors Spinal cord injury Traumatic brain injury Neuromuscular disorder Immobility Malnutrition Fecal and urinary incontinence Chronic systemic illness Fractures Aging of skin – decresed epidermal turnover - dermo -epidermal junction flattens -fewer blood vessels Decresed pain perception

6. Risk factors

7. Thermodynamics, Metabolism and pressure in relation to decubitus ulcer Thermodynamic factors- skin-surface interface As temperature increases, skin becomes more metabolically active and O2 demand increase With increased pressure , metabolic demands not able to be met and skin becomes hypoxic. Hypoxic skin more susceptible to breakdown Adding friction and shear to already fragile skin is the ‘perfect storm’.

8. The 4 forces involved in decubitus ulcer Pressure -forces applied to soft tissue between hard surface and bony prominence. When skin and the underlying tissues are trapped between bone and a surface such as wheel chair or bed, blood flow is restricted. This deprives tissue of oxygen and other nutrients  tissue death Friction -resistance of one body sliding or rolling over another. Making skin more succeptible to pressure sore

9. Shear -this occurs when skin moves in one direction and the underlying bones moves in another - Sliding down in bed or chair or raising the head of bed more than 30 degree is especially causes shearing, which stretches and tears cell membranes and tiny blood vessels -Especially affected are areas such as tailbone where skin is already thin and fragile Strain -tissue deformation in response to injury

10. Pressure and Shear

11. McClemont pressure Theory McClemont  (1984) discovered that the pressure exerted on the deeper tissues was far greater than that at the surface, resulting in a greater degree of tissue damage nearer the bone than on the skin surface. This phenomenon is known as  McClemont's  'cone of pressure theory ’

12. When a person is lying or sitting, pressure is transferred from the external surface, through the layers of the skin, toward the underlying bone. Skin, blood vessels, subcutaneous fat and muscle are compressed between the bone (which acts as a counter pressure) and the external surface.  This results in a cone, or pyramid shaped, pressure gradient. The apex of the cone equates to the bony surface where tissue interface pressures are highest. This leads to the intensity of pressure being up to five times greater on deep tissues (muscles/bony surfaces) than that on the epidermis.  Deep tissue necrosis often occurs first at the bony interface as a result of this pressure, and the fact that muscle tissue is more sensitive and less resistant to pressure than the skin. Pressure exerted at the bony interface then emerges at a point in the surface of the skin. A small, inflamed area, over a bony prominence, may indicate tissue breakdown that is much deeper and wider than indicated at the surface of the skin

13. Most susceptible tissue to pressure injury -Muscles >> subcutaneous fat >>dermis -Greatest pressure at bony prominence (Cone distribution) Pressure distribution Sitting position- Ischial tuberosity (100mm Hg) Supine position – Sacrum (150mm Hg) and Heel (40 mm Hg) Prone position- knee and chest (40mm Hg)

14. patho -physiology

15. Vulnerable areas in different position

16. Vulnerable areas

17. Most common areas

18. Staging of bed sores (As per the American National Pressure Ulcer Advisory Panel )

19. Management Multidisciplinary approach required Surgeon Plastic surgeon Neurosurgeon Orthopedic surgeon Nurses Social workers Physician Dietician Physiotherapy

20. Diagnosis Aim Determining the vulnerable individual Risk assessment Skin assessment Ulcer assessment

21. People vulnerable are Post operative period/post surgery Those who are under Critical care Orthopedic patient Spinal injured Diabetic people Affected by Peripheral vascular disease Previous history of pressure ulcers Extreme age

22. Risk assesment

23. If ulcer is present Look for -persistent erythema Non blanching erythema Blisters Localised heat Localised edema Localised induration Localised coldness Site,size,shape , surrounding, edge, base and colour Any discharge Necrotic tissue odour

24. Ulcer assessment

25. Investigation Blood sugar, CBC, CRP, ESR Wound swab microscopy ,culture and sensitivity Serum protein assessment (Albumin) Biopsy from the edge of the ulcer X –ray of the affected part

26. Prevention 1.Repositioning Frequency- 2hrly on bed and 15min on wheel chair Assisted or by self Use of devices like specialised wheel chair or mattress 2.protect bony areas Special cushions Foam mattress pad Air/water filled mattress

27. 3. Skin care Bathing Skin protecting agent (Talcum powder) Frequent skin inspection Managing incontinence/UTI 4. Improve nutrition High protein ,high carbohydrate diet Dietary supplement vit . C, Vit A and Zinc

28. 5. Early mobilization 6. Quit use of tobacco 7. Control spasticity 8. Adequate pain control 9.Psychological counseling 10.Pressure measurement by means of specialized pressure mat

29. Treatment Non surgical Pressure reduction method change of position every 2hr Mattress system Management of patient factors like infection, Diabetes, nutrition and supplement Cleaning of the wound and dressing, control of incontinence Management of pain and spasm to avoid further injury Educating the care giver

30. operative Pre operative consideration Determine whether the underlying cause can be eliminated post operatively Patient/ care giver education about the treatment Nutritional consideration (s. albumin >3.5gm/ dL ) wound debridement To rule out presence of osteomyelitis Sterilization of urinary tract

31. Debridement Contraindication Absence of necrotic tissue Granulation tissue is present

32. Intra operative Excision of the ulcer, surrounding scar and soft tissue calcification Radical removal of underlying bone and any heterotopic ossification Padding of bone stumps and filling dead space with fascia or muscle flaps Resurfacing with large regional pedicle flap Grafting the donor site of the flap with thick split skin

33. Example of flaps to be raise include Tensor fascia latae flap Transverse lumbosacral flap Sliding gluteal flap Hamstring V-Y advancement flap Rhomboid double Z plasty Gluteus maximus island flap

34. Vacuum Assisted Closure

35. Post operative measures Continue care similar to pre-operative care Prevent pressure or shearing force Drain Psychosocial support Rehabilitative care Prevention of contamination (with feces , urine) Prevention of recurrence

36. Specific treatment guided by stage Stage-I covered with transparent film Protection and prevent from further progression

37. Stage-II ulcer Require moist wound environment and minimal debridement Semi-occlusive (transparent film) or occlusive dressings (hydrocolloids or hydrogels ) Contraindication-infection

38. Stage-III and Stage-IV ulcer Through debridement of necrotic tissue Cover with appropriate dressings Treatment of infection

39. Role of antibiotics Indications In infected decubitus ulcer -Antibiotics(adjunctive) + Debridement -Prevent the infection from spreading Topical antibiotics should be avoided Antiseptic cream ( Nano silver cream ) may be applied topically

40. PUSH tool for Ulcer healing The Pressure Ulcer  Scale  for Healing (PUSH) tool is a fast and accurate tool used to measure the status of pressure wounds over time. The tool was designed by the National Pressure Ulcer Advisory Panel (NPUAP) and has been validated many times .

41. Document all observation over time .Describe each ulcer to track progress of healing

42. Complications Osteomyelitis Pyoarthrosis Anemia Urethral fistula Recurrence Autonomic dysreflexia (Spinal cord injury cases during debridement) Malignant transformation Depressive illness Hematoma and seroma (after reconstructive surgery )

43. Conclusion Decubitus ulcer management is challenging both to the patient and the managing team. It is associated with high morbidity, mortality and economic burden. Always remember that it is easier to prevent than treat a decubitus ulcer. The preventive approach on a hospitalised patient can be easily remembered as a mnemonic “ NO ULCERS SKIN ”

44. NO ULCERS N utrition and fluid status O bservation of skin U p and walking or assist with position changes L ift, don’t drag C lean skin and continence care E levate heels R isk assessment S upport surfaces SKIN S urface selection K eep turning I ncontinence management N utrition