PRESSURE SORE

DISCUSS THE MANAGEMENT OF PRESSURE SOREBy DR Kabiru Salisu NOHD

INTRODUCTIONMANAGEMENT - DiagnosisTreatmentComplicationCONCLUSIONREFERANCES

INTRODUCTIONDefinition- This is a representative of traumatic ulcer due to direct pressure on bony tissues or shearing forces resulting in microvascular compromise leading to tissue necrosis and ulceration- Decubitus Ulcer;- Latin decumbere means "to lie down

(while lying supine or sitting dawn) or (while sliding down a bed or a chair).3

HistoryThompson Rowling 1861Devis 1938

Pressure sores are an ancient problem, observed at autopsy of Egyptian mummies in 1861 by Thompson Rowling, In 1938, Davis was the first to suggest replacing the unstable scar of a healed pressure sore with a flap of tissue.[1] In 1947, Kostrubala and Greeley recommended excising the bony prominence and adding padding for the exposed bone with local fascia or muscle-fascia flaps4

EpidemiologyPressure sores are common conditions among patients hospitalized in acute- and chronic-care facilitiesHospitalised 3-10%Studies reported prevalence rates as high as 25-33% In SCI 57.1% FMC Gombe and NOHI

Studies have suggested that, at any given time, 3-10% of hospitalized persons have pressure sores5

Management of pressure sore

MultidisplinaryPlastic surgeonNeurosurgeon Orthopedic surgeon NursesSocial workersPhysicianDietitianPhysiotherapy

A- Diagnosis Aim at: - Determining the vulnerable individuals - Risk assessment - Skin assessment - Ulcer assessment

1- People vulnerable to pressure ulcers- Post surgery - Critical care- Orthopaedic patient -Spinal injured - Diabetes - Peripheral vascular disease- Previous history of pressure ulcers -Extremes of age.

2- RISK ASSESSMENT

RISK SCORING

Scores range from 5 (greatest risk) to 20 (least risk). In a series of 250 geriatric patients, 24% developed pressure ulcers at some time during their hospital stay. Patientswith a score of 11 or less had a 48% incidence of pressure ulcer; those with a score of 12 to 14 had a 32% incidence; and when the score was 18 or greater, only 5% of patients developed pressure ulcers. Gosnell107 added nutritional status of thepatient as a variable in pressure sore risk calculation. His method is often referred to as the modifiedNorton scale.11

Score ranges between 4-20, the higher the score the lower the risk 18 assocd with < 5% riskBraden, Gosnell, Knoll, Norton, Waterlow, andDouglas.12

Inspect the vulnerable areas

Characterised the ulcer if presentLook for: persistent erythema non-blanching hyperaemia blisters localised heat localised oedema localised induration purplish/bluish localised areaslocalised coldness

- site, Size, shape, surrounding, edge , base & colorDischargeBleedingNecrotic tissueOdour

localised coolness showed tissue death occurs14

4- classify the ulcer

InvestigationFBCWound swab M/C/SSerum protein (Albumin / transferin)E/UX-RayBiopsy

TREATMENT A- NON OPERATIVE

PREVENTION1- Repositioning 2- Protect bony areasfrequency- 2hrly on bed15min wheelchairAssisted/ by selfDevices eg specialise wheelchair or mattress eg trapeze bar

Special cushions foam mattress pads, air-filled mattresses water-filled mattresses/ glovesBed sheet should be smooth

Repositioning devices. People with enough upper body strength may be able to reposition themselves with the assistance of a device such as a trapeze bar. Using bed linens to help lift and reposition a person can reduce friction and shearing.Special mattresses and support surfaces. Special cushions, foam mattress pads, air-filled mattresses and water-filled mattresses can help a person lie in an appropriate position, relieve pressure and protect vulnerable areas from damage. Your doctor or other care team member can recommend an appropriate mattress or surface.18

3- Skin care

4- Improve NutritionBathingSkin protecting agent eg talcum powderfrequent skin inspectionManaging incontinence/ UTI

Good dietDietary suppliment vit. C, A, and Zinc- Feeding Assistance

5 - Early mobilization6- Quit smoking7- Control spasticity8- Adequate pain control9- psychological counseling

10- pressure measurement

Pressure mat / map

One clear advantage of pressuring mapping devices is that they provide a visual image of thepressure profile (map) of a persons interface pressure distribution. The left diagram shows apressure mat which has more than 200 individual measurement cells. The right diagram showsthe read out on the computer screen of the pressure map from the individual cells. The darkgreen areas are the maximum pressure areas which normally fall under the ischial tuberosities(the sitting bones). Cushion selection attempts to minimize these high pressure areas.22

Pressure mapping system

One clear advantage of pressuring mapping devices is that they provide a visual image of thepressure profile (map) of a persons interface pressure distribution. The left diagram shows apressure mat which has more than 200 individual measurement cells. The right diagram showsthe read out on the computer screen of the pressure map from the individual cells. The darkgreen areas are the maximum pressure areas which normally fall under the ischial tuberosities(the sitting bones). Cushion selection attempts to minimize these high pressure areas.23

Superficial sores (stage 1and 2)I. Take all preventive measures 2. wound dressing using aseptic technique sing N/S, hydrocolloid dressing , antibiotic gels/gauze or adhesive dressing3. Minimal wound debridement4. Determine presence of infection and treat5. Avoid urine or faecal contamination of wound6. Keep record of wound size , shape and other changes

The most common organisms found in pressure sores include Staphylococcus aureus, Proteus mirabilis, Pseudomonas aeruginosa, Bacteroides fragilis, and Bacteroides asaccharolyticus.24

7. Tetanus prophylaxis8. Antibiotic/ suppliments

Operative treatment (stage III/IV)A- preoperative considerationsDetermine whether the underlying cause can be eliminated post operativelyPatient / care giver EDUCATION about the treatmentNutritional Consideration ( SA 3.5g/100ml & transferin 220g%) Sterilize the urinary tractTreat spasticityRadical wound debridementDetermine presence of osteomylitis

Han and colleagues166 managed their patientswith a delayed two-stage operative plan. The firstoperation consisted of wound debridement andJamshidi core needle bone biopsy. The secondstage consisted of definitive musculocutaneous flapclosure if the biopsy results were negative forosteomyelitis. When biopsy results were positive,flap closure was delayed for 6 weeks and intravenousantibiotics were administered in the interimin hopes of eliminating the osteomyelitis.26

IntraoperativeExcision of the ulcer, surrounding scar, underlyingbursa, and soft-tissue calcification, Radical removal of underlying bone and any heterotopic ossificationpadding of bone stumps and filling dead space with fascia or muscle flaps Resurfacing with large regional pedicle flapGrafting the donor site of the flap with thick split skin

Example of flap to be raise include;- Tensor faciae latae flapTransverse lumbosecral flapSliding gluteal flapHamstring V-Y advancement flapRhomboid double Z plastyGluteal maximus island flap

Post operative measures

Prevent pressure or shearing forceDrainSitting begin at 4-6wksInitially 10min once or twice dailySitting period increase gradually up to 2hrs Improve nutrition

complicationsOsteomylitisPyoarthrosisAnaemiaUrethral fistulaRecurrenceAutonomic dysreflexiaMalignant transformationDepressive illness

CONCLUSIONPressure ulcer management is challenging both to the patient and the managing team. Is associated with high morbidity, mortality and economic burden. ALWAYS REMEMBER THAT IT IS EASIER PREVENTED THAN TREATED.

References Al-fallouji M. A: post graduate surgery, 2nd edition, Read publishing Ltd. 1998Onche I.I, Yiltok S.J, Obiano S. K; pressure ulcer in spinal cord injury patient in gombe Nigeria, nigerian journal of orthopaedics and trauma Vol-3 ,2004Idowu O.k, yinusa W; Risk factors of pressure ulcer in resource constrained spinal injury service, nature.com, j an. 2011Douglas A. H ; principles of pressure management, national institute on disability and rehabilitation research, sept. 1999Jeffrey E.J. etal; Pressure sore, baylor university medical centre, vol 9,2003Bed sore by Mayo foundation for medical education and research, march 2011 Bradon J. W; surgical treatment of pressure ulcer, medscape 2011Prevention and treatment of pressure ulcer, clinical guideline 29, royal collage of nursing 2006John L. Ziller; pressure ulcer, JAMA patient page , the journal of American medical associationVol296, Aug. 2006