Treatment
Medical Therapy
The first step in resolution is to reduce or eliminate the cause, that is, pressure. Specialized support surfaces are available for bedding and wheelchairs, which can maintain tissues at pressures below 30 mm Hg. These specialized surfaces include foam devices, air-filled devices, low–air loss beds (eg, Flexicair, KinAir), and air-fluidized beds (eg, Clinitron, FluidAir). Low–air loss beds support the patient on multiple inflatable air-permeable pillows. Air-fluidized beds suspend the patient as air is pumped into an air-permeable mattress containing millions of microspheric, uniformly sized, silicone-coated beads. No one device has been shown to be clearly superior over the others, but they all have been shown to reduce tissue pressure over conventional hospital mattresses and wheelchair cushions. Over 75 companies sell pressure-reduction devices, withannual industry revenues in excess of $8 billion.
Regardless of the choice of support surface, turning and repositioning the patient remain the cornerstones of prevention and treatment. This should be performed every 2 hours, even in the presence of a specialty surface or bed.
The wound and surrounding skin must be kept clean and free of urine and feces. This should be done through frequent cleansing and the establishment of a bowel and bladder regimen. Constipating agents may be helpful. Bacterial contamination must be assessed and treated appropriately. Differentiation of bacterial infection from simple contamination is best made with a tissue biopsy, which allows quantitative wound culture techniques. This will indicate whether antibiotics should be administered.
Wound dressings vary with the state of the wound. A stage I lesion with signs of impending breakdown may require no dressing. Stage II ulcers confined to the epidermis or dermis may be treated with a hydrocolloid occlusive dressing (DuoDerm), which maintains a moist environment to facilitate reepithelialization. For more advanced ulcers, a large variety of treatment options is available. These include wet-to-dry dressings, incorporating isotonic sodium chloride solution or dilute Dakins solution (sodium hypochlorite), Silvadene, Sulfamylon, hydrogels (Carrington gel), xerogels (Sorbsan), and vacuum-assisted closure (VAC) sponges. Daily whirlpool use also may serve to irrigate and mechanically débride the wound.
The choice of treatment and dressings is not as important as their appropriate application. These dressings are not a substitute for sharp débridement in severely contaminated wounds with necrotic material. Although uncommon, grossly infected pressure sores can lead to sepsis, myonecrosis, necrotizing fasciitis, and gangrene if not adequately débrided.
Spasticity should be relieved with diazepam, baclofen, dantrolene sodium, mephenesin carbonate, dimethothiazine, or orciprenaline. Flexion contractures may be relieved surgically.
Nutritional status should be evaluated and optimized. This is one of the only contributing factors that may be considered reversible. This may require dietary supplements, enteral feedings, or even parenteral feedings. Restoring a positive nitrogen balance and a serum protein level of 6 mg per 100 mL or higher has been shown to facilitate wound healing.
A multidisciplinary approach can lead to maximum benefit for the patient. Consultations with a neurosurgeon, urologist, plastic surgeon, orthopedic surgeon, and general surgeon all may be indicated in a particular patient. A rehabilitation medicine specialist, social worker, and psychologist or psychiatrist may work together with geriatricians or internists to improve the patient's health, attitude, support structure, and living environment.
When medical management has been optimized, many stage I and stage II pressure sores heal spontaneously. However, stage III and stage IV ulcers almost always require a surgical approach. Plastic surgeons perform most pressure sore reconstructions, and consulting a plastic surgeon with any complex or chronic wound is appropriate.
Surgical Therapy
Even with optimal medical management, many patients require a trip to the operating room for débridement, diversion of the urinary or fecal stream, release of flexion contractures, wound closure, or amputation.
Débridement is aimed at removing all devitalized tissue that serves as a reservoir for ongoing bacterial contamination and possible infection. Extensive débridement should be done in the operating room, but minor débridement is commonly performed at the bedside. Although many of these patients are insensate, others are unable to communicate pain sensation due to underlying disease processes. Pain medication should be administered liberally, and vital signs often are a good indicator of pain perception. Care also should be taken when débriding at the bedside because wounds may bleed significantly.
Urinary or fecal diversion may be necessary to optimize wound healing. Many of these patients are incontinent and their wounds are contaminated with urine and feces daily. Patients with loose stools benefit from constipating agents and a low-residue diet.
Release of flexion contractures resulting from spasticity may assist with positioning problems, and amputation may be necessary for a nonhealing wound in a patient who is not a candidate for reconstructive surgery.
Reconstruction of a pressure ulcer is aimed at improvement of patient hygiene and appearance, prevention or resolution of osteomyelitis and sepsis, reduction of fluid and protein loss through the wound, and prevention of future malignancy (Marjolin ulcer).
Preoperative Details
The concept that medical management must be optimized prior to surgical reconstruction of a pressure sore cannot be overemphasized; otherwise, reconstruction is doomed to failure. This means that spasticity must be controlled, nutritional status must be optimized, and the wound must be clean and free of infection.
Two units of type-specific packed red blood cells should be available during the operation, because blood loss may be significant.
Intraoperative Details
Patient positioning is dictated by the location of the ulcer and the planned reconstruction. Many pressure sores occur in the gluteal region and require prone positioning. Most anesthesiologists choose to use general endotracheal anesthesia, particularly if the patient is prone, but ulcer closure may be performed under regional or local anesthesia if necessary.
The first step is to adequately excise the ulcer. This includes the bursa or lining of the ulcer, surrounding scar, and any heterotopic calcification found. Underlying bone must be adequately débrided to avoid a retained nidus of osteomyelitis. Some evidence in the literature indicates that pulsed lavage can be beneficial in reducing bacterial counts in wounds, and some surgeons routinely use this method following débridement.
Once appropriately débrided, the wound may be closed in a variety of ways depending on the location of the pressure sore, previous scars or surgeries, and surgeon preference. However, the tenets of reconstruction remain the same in all pressure sore reconstructions.
Very few pressure sores can or should be closed primarily following débridement because of unacceptably high complication rates. A well-vascularized pad of tissue should be placed in the wound. This tissue usually is a musculocutaneous flap transposed or rotated on a pedicle containing its own blood supply. This also may involve the use of tissue expansion or a free flap with microvascular anastomosis. The purpose of this tissue is to eliminate dead space within the wound, enhance perfusion, decrease tension on the wound closure, and provide a new source of padding over the bony prominence. (See images below and Images 3-4.)
Small sacral pressure sores can be reconstructed with the inferior-based skin rotation flap, with or without the superior gluteus maximus myocutaneous flap.
Sacral pressure ulcer before and after flap closure.
Prior to wound closure, drains should be placed in the bed of the wound. This allows external drainage of any fluid that may accumulate beneath the flap and hopefully avoids wound complications, such as hematoma or seroma.
Postoperative Details
The ultimate success or failure of pressure sore reconstruction only begins in the operating room. Wound healing and prevention of recurrence become the goals following successful closure of a pressure sore.
Postoperatively, the patient should be maintained on a specialized support surface for no fewer than 6 weeks. This may be in the hospital, at a rehabilitation facility, or at home.
After approximately 6 weeks, at the discretion of the surgeon, patients may gradually reintroduce temporary pressure to the surgical site by sitting. The patient must accept the responsibility that he or she never again sits for more than 2 hours in one position.
Perform skin care daily. This involves a careful inspection of all skin surfaces to identify areas of impending breakdown prior to their occurrence. Skin should be washed with soap and water and completely dried. Moisture should not be allowed to accumulate on the skin or in clothing or bedding, nor should the skin be allowed to become overly dry and scaly. Skin moisturizers are useful to maintain the appropriate level of moisture at the surface of the skin.
Control of spasticity and maintenance of adequate nutrition also must be continued into the outpatient setting to prevent recurrence.
Follow-up
Follow-up should be performed every 3 weeks for the first several months. The interval may then be increased to every 6 months and then yearly. Early issues include suture removal, drain removal, and when to allow the patient to exercise or sit up.
Once healing is complete, long periods of uninterrupted pressure must be avoided. This involves frequent repositioning by the patients themselves or their support group. Seated patients with upper extremity function should lift themselves from their wheelchair for at least 10 seconds every 10-15 minutes. Patients in bed should be repositioned at least every 2 hours.
Pressure dispersion, through the application of specialized support surfaces on beds and wheelchairs, should be extended through the wound healing period and into the outpatient setting if available and tolerated by the patient. This is an adjunct to the alternating of weight-bearing surfaces and maintains low pressures on the tissues at all times.
Complications
Complications fall into 1 of 2 categories: complications of chronic ulceration and complications of ulcer reconstruction.
The most serious complication of chronic ulceration is malignant degeneration (or Marjolin ulceration). Initially described by Marjolin in 1828 as a cancer arising in burn scars, malignant degeneration has been reported in patients with chronic pressure sores. These malignancies typically are highly aggressive squamous cell carcinomas with a high likelihood of nodal metastasis at the time of diagnosis. Any long-standing, nonhealing wound should alert the examiner to the need for biopsy. (See images below and Images 5-6.)
Heaps of verrucous white tissue around the ulcer suggest malignant transformation, as observed with Marjolin ulcers.
Close-up view of area with heaps of verrucous white tissue around the ulcer, the presence of which suggests malignant transformation (as observed with Marjolin ulcers).
Complications as a result of reconstructive surgery are, unfortunately, considerable. These include hematoma, seroma, wound dehiscence, wound infection, and recurrence. Because of the use of well-vascularized flaps, flap necrosis is infrequent.
More on Decubitus Ulcers |
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 Treatment: Decubitus Ulcers |
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References
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Further Reading
Related eMedicine topics:
Pressure Ulcers and Wound Care
Pressure Ulcers, Nonsurgical Treatment and Principles
Pressure Ulcers, Surgical Treatment and Principles
Wound Care
Wound Healing, Chronic Wounds
Clinical guidelines:
Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury
Risk Assessment and Prevention of Pressure Ulcers
Clinical studies:
An RCT on Preventing Pressure Ulcers With Wheelchair Seat Cushions
Pressure Ulcer Prevention: Turning for Ulcer Reduction (TURN)
Keywords
decubitus ulcer, decubitus, pressure ulcer, pressure ulcers, bed sores, bed sore, pressure sore, pressure sores, bedsores, diabetic ulcer, decubitus ulcers, pressure ulcer staging, decubitus sore, ischial tuberosity ulcer, bed ridden, bedridden, bed rest injury, bedrest injury, chronic ulceration, pressure ulceration, decubitus ulceration
