PRESSURE SORES By Dr Zahid Iqbal Bhatti Trainee Registrar

Definition Soft tissue injuries resulting from unrelieved pressure over bony prominences. The Term “Bed sores or decubitus ulcer” should be avoided as they point out that all the sores are the result of supine position. In the lying position,the tissue destruction can occur over sacrum, scalp, shoulders, calves,and heels.

In the sitting or wheel chair position, the sores develop at the ischial area. Relieving the pressure is the key factor to healing and key to prevention. Poor nutrition, incontinence with persistent soilage and moisture, dementia, paralysis and friction make the healing less likely.

Risk factors Age Impaired sensory perception Moisture Immobility Poor Nutrition Friction

Stages of Pressure Sores Stage 1. skin Intact but reddened for more than one hour after relief of pressure

Stage 2 Blister or other break in the dermis with or without infection.

Stage 3 subcutaneous destruction in to the muscle with or without infection.

Stage 4 Involvement of the bone or joint with or without infection

What is seen on the surface is often the tip of ICE BURG In general, approximately 9% of all hospitalized develop pressure sores

Pathophysiology Factors involved 1. Pressure 2. Infection 3. Edema 4. Altered Neurological state Factors involved 1. Pressure 2. Infection 3. Edema 4. Altered Neurological state

Pathophysiology Compression of the soft tissue results in ischemia and if not relieved, will progress to necrosis and ulceration even in the vascularized area In Susceptible patients, it is accelerated by infection, inflammation and edema.

Cont- If the external pressure exceeds capillary bed pressure, capillary perfusion is impaired and ischemia results. There is an inverse relationship between the amount of pressure and the length of time required to cause ulceration..

Cont- The initial pathological changes occur in the muscles overlying the bones followed by more superficial tissue and skin in last Denervated and compressed skin becomes edematous which plays an important role in the pressure sore formation.

PREOPERATIVE CARE Preparing the patient & family for long term management requires team approach: Internal medicine Endocrinology Neurology Urology Nutritionist Physical & occupational therapy Psychiatry Specialist Nurse

Cont- Care of the pressure sore is not only the care of the wound. It includes the systemic strategy including nutritional assessment and maintenance, control of infection both local and systemic and pressure and spasm relief.

Preoperative care Nutrition Treatment of infection Relief of pressure Management of spasm Contracture therapy

1-Nutrition Normal healing potential exists when the serum albumin is above 2.0 g/dl Daily requirement of person g/dl of protein and cal/kg of non protein Exercise should be added to increase protein synthesis and anabolic drive. Vitamin C and A and Zinc.

2-Infection Pressure sores may or may not be present with local infection If infection present,should be debrided either at bed site or O.R. and small amount sent for microbiology Swabbing should be avoided Antibiotics (Local or systemic) if infection or Escher present.

These are at the risk of UTI and RTI infections. If present UTI treated by antibiotic and change of catheter if present. If Pneumonia then Positioning, side to side rolling, deep breathing and chest physiotherapy with bronchodilators.

3-Relief of Pressure This should be the prime goal. Healing will not occur in the presence of ischemia or infection. Frequent turning and intermittent elevation of the hips in the wheel chair Various mattress and wheelchair padding.

Management of spasm Most common in spinal cord injuries 100% in cervical 75% in thoracic 50% in thoracolumber Medications Diazepam ( valium ) 10mg every 4 to 6 hours Baclofen ( Lioresal ) 5mg every 6 hours Dantrolene ( Dantrium ) 25mg every 12 hours.

Contracture therapy Tightening of muscle & joint capsule Physiotherapy Tenotomies

SURGICAL & NON SURGICAL TREATMENT

Non surgical treatment Some patients may never be candidate for surgical correction due to medical problems Avoidance of unrelieved pressure Control of infection Control of incontinence Improved nutrition

Surgical treatment Three principles 1. Excisional debridment of the ulcer, its bursa, and any calcification. 2. Partial or complete ostectomy to reduce the bony prominence. 3. Wound closure with healthy tissue.

1-DEBRIDEMENT DEBRIDEMENT of any dead, necrotic tissue after instillation of methylene blue and Hdrogen peroxide. Viable tissue specimen sent for quantitative culture Post operatively, wound packed and dressing changed every 6-8 hrs.

2-OSTECTOMY Removal of bony prominences in an integral part of surgical treatment of bed sores. Radical Ostectomy avoided. Removing minimum amount of bone necessary.

3-PRESSURE SORE CLOSURE Considering not only the present surgery but also need for subsequent Procedure. Choice depends upon site, size, depth and previous surgery. Primary closure avoided. Skin Grafting has 30% success rate. Use of flaps

Pressure sore closure Advantage of Musculocutaneous flap: 1. Excellent blood supply 2. Provision of bulky padding 3. Ability to readvance or rotate flaps to treat recurrence.

Pressure sore closure Disadvantages: 1. Tissue most sensitive to external pressure. 2. May be atrophic in elder patients. 3. Functional deformity in ambulatory patients.

ISCHIAL DEFECT Seated position High recurrence rate 75% about. Medially Based thigh flap Gluteus maximus Myocutanuous flap V-Y pattern Biceps femoris, semimembrenosis, semitendinosis TFL flap.

SACRAL DEFECT. Supine position Gluteus Maximus Muscle flap. Either rotated, advanced or turn over Transverse and vertical lumbosacral flap.

TROCHANTRIC DEFECT Patients in lateral position esp. in hip flexion contracture. Commonly used is TFL flap. Rotation results in T shaped junction between flap and closed donor site which is prone to dehiscence.

Others Options For Multiple pressure sores and multiple previous procedures No local options remaining. In extreme cases, Total Thigh flap in which femur removed and thigh tissue for closure of wound.

Postoperative care Continuation of preoperative care Care full nursing care 1. Positioning of patient ( not lying on the surgical site ) 2. Special mattress

Nursing Care 1. Avoid maceration the wound 2. Antibiotics Keep it clean & dry. 3. After 2 – 3 days transferred to an intermediate – level care facility.

Recurrence 95% recurrence rate Causes : 1. Medical problems ( Diabetes, smoking, cardiovascular disease ) 2. Nursing care ( turning, local wound care, avoidance of urine & fecal contamination).