dermatologic disorders
Pressure Injuries
Treatment of Pressure Injuries
Pressure reduction Direct wound care Management of pain Control of infection Assessment of nutritional needs Adjunctive therapy or surgery Reducing tissue pressure is accomplished through careful positioning of the patient, protective devices, and use of support surfaces. Frequent repositioning(and selection of the proper position) is most important. A written schedule should be used to direct and document repositioning. Patients confined to a bed should be turned a minimum of every 2 hours and should be placed at a 30° angle to the mattress when on their side (lateral decubitus) to avoid direct trochanteric pressure. Elevation of the head of the bed should be minimal to avoid the effects of shearing forces. When repositioning patients, lifting devices (eg, a Stryker frame) or bed linen should be used instead of dragging patients to avoid unnecessary friction. Patients placed in chairs should be repositioned every hour and encouraged to change position on their own every 15 minutes. Protective paddingsuch as pillows, foam wedges, and heel protectors can be placed between and/or under the knees, ankles, and heels when patients are supine or on their side. Windows should be cut out of plaster casts at pressure sites in patients immobilized by fractures. Soft seat cushions should be provided for patients able to sit in a chair. Support surfacesunder patients confined to a bed can be changed to reduce pressure. They are often combined with other measures when treating pressure injuries. Support surfaces are classified based on whether they require electricity to operate. Static surfaces do not require electricity, whereas dynamic surfaces do. Although dynamic surfaces are usually recommended for more severe pressure injuries, no conclusive evidence favors dynamic over static surfaces. Static surfaces include air, foam, gel, and water overlays and mattresses. Egg-crate mattresses offer no advantage. In general, static surfaces increase surface support area and decrease pressure and shearing forces. Static surfaces have traditionally been used for pressure injury prevention or stage 1 pressure injuries. Dynamic surfaces include alternating-air mattresses, low-air-loss mattresses, and air-fluidized mattresses. In addition to reducing pressure, some mattresses increase the area of support, reduce heat and promote cooling, and decrease shear. Alternating-air mattresses have air cells that are alternately inflated and deflated by a pump, thus shifting supportive pressure from site to site. Low-air-loss mattresses are giant air-permeable pillows that are continuously inflated with air; the air flow has a drying effect on tissues. These specialized mattresses are indicated for patients with stage 1 pressure injuries who develop hyperemia on static surfaces and for patients with stage 3 or 4 pressure injuries. Air-fluidized (high-air-loss) mattresses contain silicone-coated beads that liquefy when air is pumped through the bed. Advantages include reduction of moisture and cooling. These mattresses are indicated for patients with nonhealing stages 3 and 4 pressure injuries or numerous truncal injuries (see table). Friction reductionusing barrier protectants such as petroleum jelly has been shown to reduce the friction caused by personal protective equipment by 25% immediately after application. However, frequent reapplication (every hour) is necessary to maintain the protective effect. Appropriate wound care involves cleaning, debridement, and dressings. Cleaningshould be done initially and with each dressing change. Normal saline is usually the best choice. Cleaning often involves irrigation at pressures sufficient to remove bacteria without traumatizing tissue; commercial syringes, squeeze bottles, or electrically pressurized systems can be used. Irrigation may also help remove necrotic tissue (debridement). Alternatively, a 35-mL syringe and an 18-gauge IV catheter can be used. Irrigation should continue until no further debris can be loosened. Antiseptics (iodine,hydrogen peroxide) and antiseptic washes can destroy healthy granulation tissue and thus should be avoided. Debridementis necessary to remove necrotic tissue. Necrotic tissue serves as a medium for bacterial growth and blocks normal wound healing. Methods include This method includes hydrotherapy (eg, whirlpool baths, pulsatile lavage) and most commonly Nonocclusive dressings . Cleaning wounds by irrigation at sufficient pressures can also accomplish mechanical debridement. Mechanical debridement removes necrotic debris on the wound’s surface and should only be done on wounds with very loose exudate. In wet-to-dry dressings, exudate and necrotic tissue adhere to a gauze dressing as it dries so that removal of the gauze thus debrides the wound; this method must be used cautiously because dressing changes are painful and may remove underlying healthy granulation tissue. Sharp (surgical) debridement:This method involves using a sterile scalpel or scissors to remove eschar and thick necrosis. Modest amounts of eschar or tissue can be debrided at the patient’s bedside, but extensive or deep areas (eg, if underlying bone, tendon, or joints are exposed) should be debrided in the operating room. Synthetic occlusive (hydrocolloids/hydrogels) dressings or semi-occlusive (transparent film) Occlusive dressings are used to facilitate the digestion of dead tissues by the enzymes already normally present in the wound. Autolytic debridement may be used for smaller wounds with little exudate. This method should not be used if a wound infection is suspected. Enzymatic debridement:This technique (usingcollagenase, papain, fibrinolysin, deoxyribonuclease, or streptokinase/streptodornase) can be used for patients with mild fibrotic or necrotic tissue within the ulcer. It can also be used for patients whose caretakers are not trained to do mechanical debridement or for patients unable to tolerate surgery. It is most effective after careful and judicious cross-hatching of the wound with a scalpel to improve penetration. Biosurgery:Medical maggot therapy is useful for selectively removing dead necrotic tissue; maggots (fly larvae) eat only dead tissue. This method is most helpful in patients who have exposed bone, tendons, and joints in the wound where sharp debridement is contraindicated. Dressings None In stage 1 pressure injuries subject to increased friction, transparent films are sufficient. For injuries with minimal exudate, transparent films or hydrogels, which are cross-linked polymer dressings that come in sheets or gels, are used to protect the wound from infection and create a moist environment. Transparent films or hydrogels should be changed every 3 to 7 days. Hydrocolloids, which combine gelatin, pectin, and carboxymethylcellulose in the form of wafers and powders, are indicated for pressure injuries with light exudate and can be left in place for up to 1 week depending on the amount of drainage. Alginates (polysaccharide seaweed derivatives containing alginic acid), which come as pads, ropes, ribbons, and hydrofiber dressings are indicated for absorbing extensive exudate and for controlling bleeding after surgical debridement. Alginates can be placed for up to 7 days but must be changed earlier if they become saturated. Foam dressings can be used in wounds with various levels of exudate and provide a moist protective environment for wound healing. Foam dressings must be changed every 3 to 4 days. Waterproof versions protect the skin from incontinence. Pressure injuries can cause significant pain. Pain should be monitored regularly using a pain scale. Primary treatment of pain is treatment of the injury itself, but a nonsteroidal anti-inflammatory drug (NSAID) oracetaminophenis useful for mild-to-moderate pain. Opioids should be avoided, if possible, because sedation promotes immobility. However, opioids or topical nonopioid preparations such as mixtures of local anesthetics may be necessary during dressing changes and debridement. In cognitively impaired patients, changes in vital signs can be used as indicators of pain. Pressure injuries should be continually assessed for signs of bacterial infection such as increased erythema, foul odor, warmth, drainage, fever, and elevated white blood cell count. Impaired wound healing should also raise concern of infection. These abnormal findings indicate a wound culture should be done. However, because all pressure ulcers are colonized, results should be interpreted with caution; bacterial count rather than bacterial presence should guide treatment. Local wound infection can be treated topically with agents such assilver sulfadiazine,mupirocin,polymyxin B, andmetronidazole.Silver sulfadiazineand similar opaque topical agents should be used cautiously because they can impair visualization of the underlying wound and can be difficult to remove. A 2-week trial of topical antibiotics for all clean pressure injuries that do not heal despite 2 to 4 weeks of proper treatment is recommended. Narrow-spectrum systemic antibiotics should be given for cellulitis, bacteremia, or osteomyelitis; usage should be guided by tissue culture, blood culture, or both or clinical suspicion and not by surface culture. Limiting the use of broad-spectrum antibiotics is important to help prevent adverse effects and to help prevent inducing bacterial resistance and disrupting the skin and gut microflora. Undernutrition is common among patients with pressure injuries and is a risk factor for delayed healing. Markers of undernutrition includealbumin< 3.5 g/dL (< 35 g/L) or weight < 80% of ideal. Protein intake of 1.25 to 1.5 g/kg/day, sometimes requiring oral, nasogastric, or parenteral supplementation, is desirable for optimal healing. Current evidence does not support supplementing vitamins or calories in patients who have no signs of nutritional deficiency. Multiple adjunctive therapies are being tried to promote healing: Negative-pressure wound therapy (vacuum-assisted closure, or VAC):This therapy is used to apply suction to the wound. It can be applied to clean wounds. High-quality evidence of efficacy does not yet exist, but negative-pressure wound therapy has shown some promise in small studies. Topical recombinant growth factors:Some evidence suggests that topical recombinant growth factors (eg, nerve growth factor, platelet-derived growth factor) facilitate wound healing. Cellular and tissue-based products:Cellular and acellular matrices (ie, skin substitutes) have been used to treat a variety of chronic wounds and have been reported to show benefit in advanced pressure injuries, but evidence is preliminary and controlled trials are lacking. Electrical stimulation therapy:Electrical stimulation therapy combined with standard wound therapy can increase wound healing. Therapeutic ultrasonography:Ultrasonography is sometimes used, but there is no good evidence of benefit or harm. Electrical magnetic, phototherapy (laser) heat, massage, and hyperbaric oxygen therapies:No evidence supports efficacy of these treatments. Large defects, especially with exposure of musculoskeletal structures, require surgical closure. Skin grafts are useful for large, shallow defects. However, because grafts do not add to blood supply, measures must be taken to prevent pressure from developing to the point of ischemia and further breakdown. Skin flaps, including myocutaneous, fasciocutaneous, and perforator-based flaps, are preferred and are the closures of choice over large bony prominences (usually the sacrum, ischia, and trochanters) ( Surgery reference ). Surgery may rapidly improve the quality of life in patients with pressure injuries. Surgical outcomes are best if preceded by optimal treatment of undernutrition and comorbid disorders. 1.Sameem M, Au M, Wood T, et al: A systematic review of complication and recurrence rates of musculocutaneous, fasciocutaneous, and perforator-based flaps for treatment of pressure sores.Plast Reconstr Surg130(1):67e–77e, 2012. doi: 10.1097/PRS.0b013e318254b19f 