Pressure Ulcer; Causes, Symptoms, Diagnosis, Treatment

Pressure Ulcer

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Pressure Ulcer/Bed Sores also known as pressure sores, bedsores, and decubitus ulcers, are localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of pressure, or pressure in combination with shear and/or friction. The most common sites are the skin overlying the sacrum, coccyx, heels or the hips, but other sites such as the elbows, knees, ankles, back of shoulders, or the back of the cranium can be affected.

The pressure sore is a common clinical problem, although its pathophysiology and management are poorly appreciated by many physicians. The impact of these lesions in terms of patient morbidity and rehabilitation and health care expenditures is great. Shearing forces, friction, and moisture, as well as pressure, contribute to the development of these sores. This paper reviews the clinical settings, causative factors, complications, and principles of prevention and management of the pressure sore. Early surgical consultation is important, because of the deceptive nature and multiple sequelae of these wounds.

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Pressure ulcers occur due to pressure applied to soft tissue resulting in completely or partially obstructed blood flow to the soft tissue. Shear is also a cause, as it can pull on blood vessels that feed the skin. Pressure ulcers most commonly develop in individuals who are not moving about, such as those being bedridden or confined to a wheelchair. It is widely believed that other factors can influence the tolerance of skin for pressure and shear, thereby increasing the risk of pressure ulcer development. These factors are protein-calorie malnutrition, microclimate (skin wetness caused by sweating or incontinence), diseases that reduce blood flow to the skin, such as arteriosclerosis, or diseases that reduce the sensation in the skin, such as paralysis or neuropathy. The healing of pressure ulcers may be slowed by the age of the person, medical conditions (such as arteriosclerosis, diabetes or infection), smoking or medications such as anti-inflammatory drugs.

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Types /Classification of Pressure Sores / Bed Sores

The definitions of the four pressure ulcer stages are revised periodically by the National Pressure Ulcer Advisory Panel (NPUAP)in the United States and the European Pressure Ulcer Advisory Panel (EPUAP) in Europe. Briefly, they are as follows

  • Stage 1 – Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area differs in characteristics such as thickness and temperature as compared to adjacent tissue. Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons (a heralding sign of risk).
  • Stage 2 Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.
  • Stage 3 Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable.
  • Stage 4 Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Stage 4 ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis likely to occur. The exposed bone/tendon is visible or directly palpable. In 2012, the NPUAP stated that pressure ulcers with exposed cartilage are also classified as a stage 4.
  • Unstageable Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels is normally protective and should not be removed.
  • Suspected Deep Tissue Injury A purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. A deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

different stages of pressure ulcers

Stage I
  • Nonblanchable erythema
  • Skin intact
Stage II
  • Possible blister formation
  • Partial-thickness skin damage
Stage III
  • Subcutaneous fat exposed
  • Full-thickness skin loss
Stage IV
  • Exposed muscles, bones, tendons, or vital organs
  • Skin, subcutaneous and possibly more tissue loss
Unstageable
  • Entire wound base covered by slough and/or eschar
  • Full-thickness skin loss
Deep tissue injury
  • Unknown level of tissue injured below skin
  • Skin intact

Grades of pressure ulcer [rx]

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Grade 1

  • A grade one pressure ulcer is the most superficial type of ulcer. The affected area of skin appears discolored and is red in white people, and purple or blue in people with darker colored skin [rx]. One important thing to remember is that Grade 1 pressure ulcers do not turn white when pressure is placed on them. The skin remains intact, but it may hurt or itch. It may also feel either warm and spongy or hard.

The characteristics are:

  • Non-blanchable erythema of intact skin can be difficult to assess in patients with darkly pigmented skin.
  • Oedema, induration.
  • Warmth over a bony prominence.
  • When an eschar is present, accurate staging is not possible.

Grade 2

  • In Grade 2 pressure ulcers, some of the outer surface of the skin (the epidermis) or the deeper layer of skin (the dermis) is damaged, leading to skin loss [rx]. The ulcer looks like an open wound or a blister. The characteristics are:
  • Partial thickness skin loss involving epidermis, dermis or both, for example, abrasion, blister or shallow crater.

Grade 3

  • In Grade 3 pressure ulcers, skin loss occurs throughout the entire thickness of the skin. The underlying tissue is also damaged, but the underlying muscle and bone are not damaged. The ulcer appears as a deep cavity like a wound [rx]. The characteristics are:
  • Full-thickness skins involving damage to or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia.
  • Presents clinically as a deep crater with or without undermining.

Grade 4

  • A Grade 4 pressure ulcer is the most severe type of pressure ulcer. The skin is severely damaged, and the surrounding tissue begins to die (tissue necrosis). The underlying muscles, bone or joint may also be damaged [rx], sometimes very severely [rx]. People with grade four pressure ulcers have a high risk of developing a life-threatening infection. The characteristics are:
  • Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures, for example, tendon or joint capsule. Undermining and sinus tracts may be associated with this stage of wound progression
  • Similar to grading a burn with the addition of stage 4 that is deeper than a stage 3 ulcer or 3rddegree burn.

Causes of Pressure Sores / Bed Sores

  • Pressure sores occur when there is too much pressure on the skin for too long. This reduces blood flow to the area. Without enough blood, the skin can die and a sore may form.

You are more likely to get a pressure sore if you

  • External (interface) pressure– applied over an area of the body, especially over the bony prominences can result in obstruction of the blood capillaries, which deprives tissues of oxygen and nutrients, causing ischemia(deficiency of blood in a particular area), hypoxia(inadequate amount of oxygen available to the cells), edema, inflammation, and, finally, necrosis and ulcer formation. Ulcers due to external pressure occur over the sacrum and coccyx, followed by the trochanter and the calcaneus(heel).
  • Friction is damaging to the superficial blood vessels directly under the skin. It occurs when two surfaces rub against each other. The skin over the elbows and can be injured due to friction. The back can also be injured when patients are pulled or slid over bed sheets while being moved up in bed or transferred onto a stretcher.
  • Shearing– is a separation of the skin from underlying tissues. When a patient is partially sitting up in bed, their skin may stick to the sheet, making them susceptible to shearing in case underlying tissues move downward with the body toward the foot of the bed. This may also be possible on a patient who slides down while sitting in a chair.
  • Moisture is also a common pressure ulcer culprit. Sweat, urine, feces, or excessive wound drainage can further exacerbate the damage done by pressure, friction, and shear. It can contribute to maceration of surrounding skin thus potentially expanding the deleterious effects of pressure ulcers.
  • Use a wheelchair or stay in bed for a long time
  • Are an older adult
  • Cannot move certain parts of your body without help
  • Have a disease that affects blood flow, including diabetes or vascular disease
  • Have Alzheimer disease or another condition that affects your mental state
  • Have fragile skin
  • Cannot control your bladder or bowels
  • Do not get enough nutrition

Indirect causes (associated factors)

  • Age-related physiological alterations can lower the threshold for pressure-induced injury in elderly patients. For example, an increase in the fragility of blood vessels and connective tissue and a loss of fat and muscle leading to a reduced capacity to dissipate pressure.
  • Any condition that is associated with prolonged, impaired wound healing such as diabetes mellitus, which affects 11% of adults over the age of 70 years.[]
  • Oxygen is required for all stages of wound healing thus any condition that is associated with a low tissue oxygen tension is a major cause of pressure ulcers. These include: Heart failure, atrial fibrillation, myocardial infarction, and chronic obstructive pulmonary disease.
  • Peripheral vascular disease, which affects 20% of older adults,[] has a negative impact on wound healing.
  • Contractures and spasticity can contribute by repeatedly exposing tissues to pressure through flexion of a joint.
  • Loss of sensations, the pain signal that would normally cause an immobile individual to change position is lost.
  • Paralysis and insensibility may produce atrophy of the skin leading to a thinning. This renders the skin more susceptible to the friction and shear forces a patient experiences when being moved.
  • Nutritional conditions such as malnutrition,[] hypoproteinemia,[] and anaemia[] can cause significant delays in wound healing and hasten the formation of pressure ulcers.[]
  • Moisture causes maceration, which predisposes the skin to injury. De-epithelialisation caused by trauma leads to transdermal water loss that creates maceration and adherence of the skin to clothing and any other supports in contact, resulting into further injury.[]
  • Mental health conditions – people with severe mental health conditions such as schizophrenia or severe depression have an increased risk of pressure ulcers for a number of reasons
  • Their diet tends to be poor, resulting in hypoproteinemia.
  • They may neglect their personal hygiene, making their skin more vulnerable to injury and infection that help an ulcer to form.
  • They often have other physical health conditions, such as diabetes or incontinence.

Intrinsic and extrinsic factors influencing the development of pressure ulcers

Intrinsic risk factors for development of pressure ulcers
  • Diabetes
  • Smoking
  • Malnutrition
  • Immunosuppression
  • Vascular disease
  • Spinal cord injury
  • Contractures
  • Prolonged immobility
  • Extrinsic risk factors for the development of pressure ulcers
  • Lying on hard surfaces
  • Nursing homes
  • Poorly fitting prostheses
  • Poor skin hygiene
  • Patient restraints
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Symptoms of Pressure Sores / Bed Sores

Pressure sores are grouped by the severity of symptoms. Stage I is the mildest stage. Stage IV is the worst.

Stages of pressure sores

STAGE 1

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Signs
Skin is not broken but is red or discolored or may show changes in hardness or temperature compared to surrounding areas. When you press on it, it stays red and does not lighten or turn white (blanch). The redness or change in color does not fade within 30 minutes after pressure is removed.

What to do

  • Stay off the area and remove all pressure.
  • Keep the area clean and dry.
  • Eat adequate calories high in protein, vitamins (especially A and C) and minerals (especially iron and zinc).
  • Drink more water.
  • Find and remove the cause.
  • Inspect the area at least twice a day.
  • Call your health care provider if it has not gone away in 2-3 days.

Healing time

  • A pressure sore at this stage can be reversed in about three days if all pressure is taken off the site.

STAGE 2

Signs

  • The topmost layer of skin (epidermis) is broken, creating a shallow open sore. The second layer of skin (dermis) may also be broken. Drainage (pus) or fluid leakage may or may not be present.

What to do

  • Get the pressure off.
  • Follow steps in Stage 1.
  • See your health care provider right away.

Healing time:

  • Three days to three weeks.

STAGE 3

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Signs

  • The wound extends through the dermis (second layer of skin) into the fatty subcutaneous (below the skin) tissue. Bone, tendon, and muscle are not visible. Look for signs of infection( redness around the edge of the sore, pus, odor, fever, or greenish drainage from the sore) and possible necrosis (black, dead tissue).

What to do

  • If you have not already done so, get the pressure off and see your health care provider right away.
  • Wounds in this stage frequently need special wound care.
  • You may also qualify for a special bed or pressure-relieving mattress that can be ordered by your health care provider.

Healing time

  • More than one to four months.

STAGE 4

Signs

  • The wound extends into the muscle and can extend as far down as the bone. Usually lots of dead tissue and drainage are present.
  • There is a high possibility of infection.

What to do

  • Always consult your health care provider right away.
  • Surgery is frequently required for this type of wound.

Healing time

  • Anywhere from three months to two years.

Suspected Deep Tissue Injury

  • A purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be surrounded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to nearby tissue.
  • Deep tissue injury may be difficult to detect in individuals with dark skin tones. Progression may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar (scab). Progression may be rapid exposing additional layers of tissue even with optimal treatment.

Unstageable

  • Full thickness tissue loss in which the base of the sore is covered by slough (dead tissue separated from living tissue) of yellow, tan, gray, green or brown color, and/or eschar (scab) of tan, brown or black color in the wound bed.
  • Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema (abnormal redness) or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.

Possible complications of pressure sores

  • Can be life-threatening.
  • Infection can spread to the blood, heart, and bone.
  • Amputations.
  • Prolonged bed rest that can keep you out of work, school and social activities for months.
  • Autonomic dysreflexia.
  • Because you are less active when healing a pressure sore, you are at higher risk for respiratory problems or urinary tract infections (UTIs).
  • Treatment can be very costly in lost wages or additional medical expenses.

There are 2 other types of pressure sores that don’t fit into the stages.

  • Sores covered in dead skin that is yellow, tan, green, or brown. The dead skin makes it hard to tell how deep the sore is. This type of sore is unstageable.
  • Pressure sores that develop in the tissue deep below the skin. This is called a deep tissue injury. The area may be dark purple or maroon. There may be a blood-filled blister under the skin. This type of skin injury can quickly become a stage III or IV pressure sore.

Pressure sores tend to form where skin covers bone, such as your

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  • Buttocks
  • Elbow
  • Hips
  • Heels
  • Ankles
  • Shoulders
  • Back

Back ofheat treatmentt

of Pressure Sores / Bed Sores

Treating pressure ulcers is not easy

  • An open wound is unlikely to heal rapidly. Even when healing does take place, it may be inconsistent, because of the damage to skin and other tissues.
  • Less severe pressure ulcers often heal within a few weeks with proper treatment, but serious wounds may need surgery.

The following steps should be taken

  • Remove the pressure – from the sore by moving the patient or using foam pads or pillows to prop up parts of the body.
  • Clean the wound – Minor wounds may be gently washed with water and mild soap. Open sores need to be cleaned with a saline solution each time the dressing is changed.
  • Control incontinence – as far as possible.
  • Remove dead tissue – A wound does not heal well if dead or infected tissue is present, so debridement is necessary.
  • Apply dressings –These protect the wound and accelerate healing. Some dressings help prevent infection by dissolving dead tissue.
  • Use oral antibiotics or antibiotic cream – These will can help treat an infection.
  • Pressure ulcers – are a complex health problem arising from many interrelated factors. Therefore, your care may be provided by a team that is made up of different types of healthcare professionals. This type of team is sometimes known as a multidisciplinary team (MDT).

Additional treatment

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Your MDT may include

  • a tissue viability nurse (a nurse who specializes in wound care and prevention)
  • a social worker
  • a physical therapist
  • an occupational therapist
  • a dietician
  • medical and surgical experts with experience in pressure ulcer management

Changing position

It is important to avoid putting pressure on areas that are vulnerable to pressure ulcers or where pressure ulcers have already formed. Moving and regularly changing your position helps to:

  • prevent pressure ulcers developing in vulnerable areas
  • relieve the pressure on any grade one or grade two pressure ulcers that have developed
  • After your risk assessment is completed, your care team will draw up a ‘repositioning timetable’, which states how often you need to be moved. For some people, this may be as often as once every 15 minutes. Others may need to be moved only once every two hours.
  • The risk assessment will also consider the most effective way to avoid putting any vulnerable areas of skin under pressure whenever possible.

A nurse or physical therapist may also give you training and advice about:

  • correct sitting and lying positions
  • how you can adjust your sitting and lying position
  • how often you need to move or be moved
  • how best to support your feet
  • how to keep a good posture
  • the special equipment that you should use and how to use it

Mattresses and cushions

  • There are a range of special mattresses and cushions that can relieve pressure on vulnerable parts of the body. Your care team will discuss the types of mattresses and cushions that are most suitable for you.
  • People who are thought to be at risk of developing pressure ulcers, or who have pre-existing grade one or two pressure ulcers, usually benefit from resting on a specially designed foam mattress, which relieves the pressure on their body.
  • People with a grade three or four pressure ulcer will require a more sophisticated mattress or bed system. For example, there are mattresses that can be connected to a constant flow of air, which is automatically regulated to reduce pressure as and when required.

Dressings

Specially designed dressings and bandages can be used to protect pressure ulcers and speed up the healing process. Examples of these types of dressing include:

  • hydrocolloid dressings – these contain a special gel that encourages the growth of new skin cells in the ulcer while keeping dry the surrounding healthy area of skin
  • alginate dressings – these are made from seaweed and contain sodium and calcium, which are known to speed up the healing process

Topical preparations

  • Topical preparations, such as cream and ointments, can be used to help speed up the healing process and also prevent further tissue damage.

Antibiotics

  • If you have a pressure ulcer, you will not routinely be prescribed antibiotics. Antibiotics are usually only prescribed to treat an infected pressure ulcer and prevent the infection from spreading. Antiseptic cream may also be applied directly to pressure ulcers to clear out any bacteria that may be present.
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  • Cleaning of the wound and meticulous skin care are the most essential part of the treatment. The process involves the removal of surface contamination and meticulous excision of all dead tissue. This is debridement. Besides the conventional surgical debridement other types of debridement like mechanical debridement which includes use of repeated wet to dry dressings to removes slough,[] enzymatic debridement using enzymes to liquefy dead tissue in the wound and remove them with the dressings,[] and biological debridement or maggots and larval therapy[,] (in which the larvae eat all the dead tissue and make the wound clean without harming the living tissues) also find a mention in literature.
  • Maggots also help to fight infection by releasing substances that kill bacteria and stimulate the healing process.[] Sharp surgical debridement using blade or scissors is the most commonly used and most effective method of debridement in able surgical hands. Dead tissue may be removed using mechanical means. Some mechanical debridement techniques include:

Cleansing and pressure irrigation

  • Where dead tissue is removed using high-pressure water jets. There is no evidence available to support any specific and effective cleansing techniques or solution, in particular.[]

Ultrasound

  • Dead tissue is removed using low-frequency energy waves.[,]

Laser

  • Dead tissue is removed using focused beams of light.[] Basically, debridement is done for converting the chronic wound into an acute wound so that it can progress through the normal stages of healing.

Antibiotics

  • All pressure sores do not require antibiotics.[] Antibiotics are usually only prescribed to treat an infected pressure ulcer and prevent the infection from spreading. If tissue infection exists, antibiotics are necessary to treat the infection, but the effort must be made to debride the ulcer thoroughly and leave all viable tissues only, otherwise, antibiotics alone will not clean up the ulcer. Antibiotics are adjunct to surgical debridement and not an alternative to it.
  • Topical antibiotics should be avoided because their use may increase antibiotic resistance and allergy. Antiseptic cream may also be applied topically to pressure ulcers to clear out any bacteria that may be present.

Biofilm

  • It has been noticed that the longstanding pressure ulcers are frequently colonized by micro-organisms in a biofilm. The biofilm may be composed of bacteria, fungi or other organisms, which are embedded in and adherent to the underlying wound.
  • The organisms are protected from the effect of conventional antibiotics; unnecessary prescription of antibiotics may, in fact, select more resistant organisms. We address the problem of biofilm by changing the pH of the wound — dressing with dilute acetic acid if it is alkaline, which it usually is and curetting out all the underminings, cracks and crevices of the ulcer or by surgical debridement.

Pressure Wound Therapy

  • This is an invaluable tool in the management of pressure sores and involves the application of sub-atmospheric pressure to a wound using a computerized unit to intermittently or continuously convey negative pressure to promote wound healing.
  • NPWT is effective for deep, cavitating, infected and copiously discharging pressure ulcers, particularly with exposed bone.[] With growing clinical experience[] it can be said with certainty that it assists wound healing, and its benefits can be summarised thus:
  • Assists granulation.
  • Applies controlled, localized negative pressure to help uniformly draw wounds closed.
  • Helps remove interstitial fluid allowing tissue decompression.
  • Helps remove infectious materials and quantifies exudates loss.
  • Provides a closed, moist wound healing environment
  • Promotes flap and graft survival.
  • Both hospital and domiciliary use.
  • Reduces hospital/dressings/nursing cost (if we can discharge the patient to home).

Newer Research

There are many supportive therapies to promote healing of pressure ulcers. While some are in clinical use others are in the realm of research. Many products are available to aid wound healing but should be prescribed only under strict medical advice, as they still require further research to determine their effectiveness. These include:

  • Growth factors and cytokines.[]
  • Hyperbaric oxygen (HBO) to increase tissue oxygen tension.[]
  • Skin graft substitutes (bioengineered skin).[]
    • Connective tissue matrix.
    • Expanded epidermis.
    • Epidermal stem cells.[]
  • Bone marrow (BM) or adipose tissue-derived stem cell (ASC) therapy.[]

Cytokines and growth factors

  • Chronic pressure ulcers display high levels of inflammation and disruption of the collagen matrix, along with increased indications of apoptosis and decreased levels of growth factors and their receptors. These characteristics can be used to comprehensively evaluate the etiology and treatment of these ulcers.[]
  • Contemporary authors head compared the healing response of sequential topically applied cytokines to that of each cytokine alone and to placebo in pressure ulcers and evaluated the molecular and cellular responses.[] Ulcers treated with cytokines had greater closure than those in placebo-treated patients.
  • Patients treated with basic fibroblast growth factor (bFGF) alone did the best, followed by the granulocyte-macrophage-colony-stimulating factor (GM-CSF)/bFGF group. Patients treated with GM-CSF or bFGF had higher levels of their respective cytokine after treatment. Patients with the greatest amount of healing showed higher levels of the platelet-derived growth factor on day 10 and transforming growth factor beta-1 on day 36.
  • Message for the bFGF gene was upregulated after treatment with exogenous bFGF, suggesting autoinduction of the cytokine. Both cytokines and growth factors may have a big role to play in the treatment of pressure ulcers in the future.
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Hyperbaric oxygen therapy

Hyperbaric oxygen therapy (HBO) is being used for the treatment of pressure sores. Specially constructed devices equipped with controlled pressure sealings and automatic relief valves are fitted in HBO chambers. A constant pressure of 22 mm Hg (1.03 atmospheres absolute) is maintained inside the chamber using pure oxygen at a flow rate of 2-8 L/min with direct discharge to the atmosphere.[] It has proven to be very successful and safe adjunctive treatment to daily wound dressing,[] administration of antibiotics and surgical debridement because:

  • It increases oxygen transport to the wound area stopping further tissue damage
  • It facilitates the growth of new capillaries (angiogenesis) improving the microcirculation
  • It speeds up wound healing by reducing inflammation and swelling
  • It relieves pain
  • It reduces infection by eliminating bacteria directly and increasing the capacity of white blood cell to fight infection
  • It improves microcirculation and elimination of toxins in the blood
  • It enhances the effect of some antibiotics
  • It stimulates the release of stem cells from the BM
  • It decreases blood viscosity and the risk of thrombosis and stroke
  • It improves lymphatic circulation
  • It improves bone density and mineralization and speeds up bone healing
  • It enhances peripheral nerve regeneration for improved sensitivity
  • It prepares tissue and bone for grafting before surgery
  • It speeds up healing after surgery and improves the chances of graft survival.

Skin substitutes (bio-engineered skin)

  • Cultured keratinocytes have been used for the treatment of various types of wounds for more than a decade.[] Researches explain that in patients with partial/full-thickness skin defects, the most effective therapy is a cultured dermal substitute (CDS), while cultured epidermal substitute and cultured skin substitute have also been used as biological wound dressings.[]
  • The artificial dermis induces angiogenesis and fibroplasia in deep, poorly vascularised tissue defects with fewer vascular invasions. However, it is difficult to apply collagen matrix to pressure ulcers, because they are usually accompanied by infection with the discharge of excessive amounts of exudate or pus and generally exposed to external forces that prevent graft fixation.[] The allogeneic CDS effectively treats intractable ulcers while BM cell implantation combined with allogeneic CDS is used in treating severely ischaemic ulcers.[]

Bone marrow/adipogenic stem cells

  • Cell therapy can be defined as a set of strategies, which use live cells for therapeutic purposes. The aim of such therapy is to repair, replace or restore the biological function of damaged tissue or organ.
  • Bone Marrow (BM)-mono nuclear cells (MNCs) can be easily obtained in large numbers by aspiration without extensive manipulation or cultivation before transplant and cells can be transplanted directly without in vitro expansion.
  • Using the entire mononuclear fraction, no potentially beneficial cell type is omitted and MNCs from a patient’s own BM promote angiogenesis[] and this seems to be a key factor for optimal healing of skin wounds.
  • Marrow stem cells (MSCs), which make up a small proportion of BM-MNCs, secrete paracrine factors that could recruit macrophages and endothelial cells to enhance wound healing.[]

Split-thickness skin grafting

  • When the ulcer is superficial and vital tissues such as bone, vessels, nerves or tendons are not exposed, and the ulcer is not copiously discharging, skin grafting is the first option for surgical treatment. The slimy layer over the surface of ulcer is sharply debrided to get a healthy vascular bed for skin grafting.

Local flaps

  • Variety of local flaps can be used to reconstruct the defect created by excision of pressure ulcers. Local transposition, rotation, limberg flap are the available options [Figures  [rx, rx]. Biceps femoris V-Y advancement (in paraplegics only) for ischial pressure sore[,] and perforator based V-Y advancement is another good options if the anatomy permits [rx].

Regional flaps

  • Sometimes the local or limberg flap cannot close the larger defects due to their size or location resulting in the need for regional flaps. For Sacral pressure sores, there are many flap options such as gluteus maximus my-cutaneous flap, Sup gluteal artery based rotation fascia-cutaneous flap, superior gluteal artery perforator flaps [rx], perforator based V-Y advancement flap, lumbogluteal sensory flap.
  • For lower extremity pressure ulcer reconstruction; Islanded Medial planter flap [rx], lateral or medial calcaneal flaps, Reverse sural flap [rx], varieties of fascio-cutaneous flaps may provide a huge reconstructive option.

Microvascular free flaps

  • Microvascular free flaps are usually reserved for some selected cases where the local and regional flap options are either not available or have failed, and the depth of the pressure ulcer demands adequate volume restoration for proper weight bearing. In fact, the latter reason is so vital that many large pressure ulcers on weight bearing soles or on tip of amputation stumps are today being primarily treated with microvascular free tissue transfer.

Wound dressings

  • The dressing used for various stages of wound healing is specialized for every stage; in fact, there is a whole range of dressings available to assist with the different stages of wound healing. These are classified as non-absorbent, absorbent, debriding, self-adhering and many others. It is vital to determine the most appropriate dressing as it ultimately depends on the site/type of ulcer, for hospital care or domiciliary management, personal preference and cost to the patient.
  • Dressings are usually occlusive, so the ulcers heal better in a moist environment. If the ulcer is clean and dry, occlusive dressings are usually changed weekly, and more frequent changes are avoided as dressing changes remove healthy cells along with debris. Contaminated or weeping wounds may require more frequent dressing changes, sometimes every few hours. Heavily contaminated ulcers are treated with negative pressure wound therapy (NPWT).[]
  • Specialized dressings and bandages are used to protect and speed up the healing process of the pressure ulcers. These dressings include:

Dressings available for pressure ulcer management with advantages, disadvantages, and ideal use

Type of DressingAdvantagesDisadvantagesIdeal Wound
Alginate dressingsAbsorbent, infrequent changesExpensiveInfected wounds
Foam dressingsAbsorbent provides paddingExpensiveInfected wounds, fragile surrounding skin, Stage I and for prevention
Gauze DressingsInexpensive, microdebridementFrequent changesLarge complex wounds with exudate or biofilm
Honey dressingsMild antibioticPoor efficacyStage II with mild infection
Hydrocolloid DressingsAbsorbentExpensiveWounds with minimal discharge, Stage II and III
Hydrogel DressingsHydratingMoves easilyDry or dehydrated wounds, uninfected granulating wounds
Silver DressingsAntibioticPrevents epithelializationInfected wounds, remove once infection is cleared
Transparent film dressingBarrier from bodily fluids, infrequent changesNot porous, can rip skin on removalStage I, Stage II without exudate

Gauze Dressings

  • The traditional wet-to-dry method of gauze dressing now has more limited use in the treatment of pressure ulcers. While the materials are inexpensive, they do require frequent changes and the related nursing expense needs to be factored in when determining their true cost.
  • When properly performed, they help maintain a moist wound environment, and the gauze also serves the role of performing a superficial debridement of biofilm and small amounts of necrotic tissue during dressing changes due to its adherent nature. The advent of advanced dressing materials makes gauze dressings a fallback when nothing else is readily available. Dry gauze dressings should not be used to treat pressure ulcers.

Alginate Dressings

  • Alginate is a very absorbent material that is ideal for use in wounds with moderate to high discharge. They can absorb several times their weight in exudate and can conform well to irregular or tunneled wounds. Alginate dressings can be used in the setting of infected wounds and can be left in place longer than most dressings.

Foam Dressings

  • Foam dressings are made from polyurethane, a semipermeable material that can accommodate a medium to high amount of wound exudate and can be used in infected pressure ulcers. Foam dressings are often used for prevention of pressure ulcers because they provide some cushion.
  • Silicone is often used in combination with foam dressings (such as Allevyn, Mepilex, and Optifoam) and is helpful in the setting of fragile tissue surrounding pressure ulcers. Dressings with silicone are less likely to cause trauma to skin on removal compared to other adherent dressings.

Hydrocolloid Dressings

  • Hydrocolloid dressings are made of a foam or film polyurethane material and contain gelatin- or sodium carboxymethylcellulose-based gel material, which gives it the ability to absorb some fluids. They are well suited for wounds that have minimal to moderate drainage and are often used on Stage II and Stage III pressure ulcers.

Hydrogel Dressings

  • Hydrogel dressings are gel based and are 90% water. These dressings are therefore ideally used in dry or dehydrated wounds and are often used over granulation tissue.
  • In addition to being available in sheet form (where hydrogel is placed over a thin fiber mesh) and in the form of impregnated gauze, hydrogel also comes in its pure form in tubes and can be placed at the base of an uninfected granulating wound. This dressing should be covered by a sturdier dressing to prevent dislocation and dehydration of the hydrogel.

Silver-containing Dressings

  • Silver has bactericidal properties and dressings that are impregnated with silver are ideal for use in infected wounds. This dressing should be discontinued after clearance of infection as it can delay wound healing due to its toxicity to keratinocytes and fibroblasts.
  • Silver is often incorporated into foam and alginate dressings. Silver alginate comes in rope and square forms, which are well suited for infected wounds with exudate, and gel form, which is better suited for drier wounds.

Honey-containing dressings

  • There are anecdotal reports of the use of honey in the treatment of wounds since antiquity. In modern times, there is currently low evidence for the use of honey in the setting of pressure ulcers. Medical-grade honey has been shown to have mild antibiotic properties.
  • Medical honey comes in stand-alone forms of gel or paste as well as impregnated into dressings where it is combined with alginate or hydrocolloid materials.

Transparent film dressings

  • Transparent film dressings are used primarily to protect Stage I or II ulcers where the skin remains intact. They provide a barrier to urine, stool, and other bodily fluids, which can macerate the skin. Because they are transparent and allow for observation of the wound, they can be applied and left in place for days.
  • These dressings should not be applied in any ulcer where there is exudate as they are not porous. Care must be taken to remove these dressings as they can rip skin if removed forcefully.

Negative pressure wound therapy

  • Negative pressure wound therapy (NPWT) consists of a foam dressing, which can be tailored to fit the patient’s wound and is covered by a transparent film to enable the creation of a vacuum in the wound when the foam is attached to a suction device via tubing. NPWT has been shown to speed wound healing in chronic wounds and the prevailing theory is that the vacuum causes the cells in the wound bed to sense a mechanical force.
  • Mechanical forces stimulate the proliferation of fibroblasts leading to improved healing. The presence of the vacuum continuously eliminates exudate making it ideal in wounds where there is heavy exudate. Before application of the NPWT device, the wound must be adequately debrided. The foam dressing is easy to conform to wounds with unusual shapes, tunneling, and undermining. Because of the transparent film required for the vacuum to hold, NPWT is useful for preventing additional wound contamination.
  • Randomized controlled trials showed no advantage of NPWT over other dressings. As with any dressing, its use is dictated by its properties. Wounds with a heavy exudate are readily managed with NPWT. It has been found to be helpful in wounds adjacent to fecal flow where its seal prevents wound contamination. Contraindications to NPWT use include uncorrected coagulopathy, exposed vital organs or large vessels. A nonadherent dressing can be placed below the foam to decrease pain on the removal of foam dressing and during suctioning over the wound bed.
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Other therapies

  • Biophysical treatments, including direct electric stimulation, pulsed electromagnetic field, and pulsed radiofrequency energy, have been used to promote wound healing. Phototherapy treatment of pressure ulcers has been performed using laser, infrared, and ultraviolet waves.
  • Studies have shown equivocal evidence concerning laser and infrared treatments, but ultraviolet C light therapy has been shown to decrease the bacterial burden and can be used following wound debridement in persistently infected wounds. Hyperbaric oxygen therapy and topical oxygen therapy have been used for pressure ulcer treatment with equivocal results.

Hydrocolloid Dressings

  • These contain a special gel that encourages the growth of new skin cells in the ulcer and keeps the nearby healthy area of skin dry.[,]

Alginate Dressings

  • These are made from seaweed that contains sodium and calcium known to speed up the healing process. Honey-impregnated alginate dressings are known to accomplish total wound healing to pressure ulcers.[]

Nanosilver dressings

  • These use the antibacterial property of silver to clean the ulcer.[,]

Creams and ointments

  • To prevent further tissue damage and help speed up the healing process, topical preparations, such as cream and ointments are frequently used.

Nutrition

Decubitus Ulcer

Certain dietary supplements, such as protein, zinc and vitamin C, have been shown to accelerate wound healing.

If your diet lacks these vitamins and minerals, your skin may be more vulnerable to developing pressure ulcers. As a result of this, you may be referred to a dietician so that a suitable dietary plan can be drawn up for you.

Debridement

In some cases, it may be necessary to remove dead tissue from the ulcer to help stimulate the healing process. This procedure is known as debridement.

If there is a small amount of dead tissue, it may be possible to remove it using specially designed dressings and paste. Larger amounts of dead tissue may be removed using mechanical means. Some mechanical debridement techniques include:

  • cleansing and pressure irrigation – where dead tissue is removed using high-pressure water jets
  • ultrasound – dead tissue is removed using low-frequency energy waves
  • laser – dead tissue is removed using focused beams of light
  • surgical debridement – dead tissue is removed using surgical instruments, such as scalpels and forceps

A local anesthetic will be used to numb the area of skin and tissue around the ulcer so that debridement does not cause any pain or discomfort.

Maggot therapy

  • Maggot therapy, also known as larvae therapy, is an alternative method of debridement. Maggots are ideal for debridement because they feed on dead and infected tissue without touching healthy tissue. They also help to fight infection by releasing substances that kill bacteria and stimulate the healing process.
  • During maggot therapy, the maggots are mixed into a wound dressing and the area is covered with gauze. After a few days, the dressing is taken off and the maggots are removed.
  • Many people may find the idea of maggot therapy off-putting but research has found that it is often more effective than more traditional methods of debridement.

Surgery of Pressure Sores / Bed Sores

  • Surgical treatment involves cleaning the wound and closing it by bringing together the edges of the wound (direct closure) or by using tissue moved from a nearby part of the body (flap reconstruction).
  • Pressure ulcer surgery can be challenging, especially because most people who have the procedure are already in a poor state of health. As a result of the risk factors, a large number of possible complications can occur after surgery, including:
  • infection
  • tissue death of the implanted flap
  • muscle weakness
  • blisters – small pockets of fluid that develop inside the skin
  • recurrence of the pressure ulcers
  • blood poisoning
  • infection of the bone – the medical term for this is osteomyelitis
  • internal bleeding
  • abscesses – painful collections of pus that develop inside the body
  • deep vein thrombosis – a blood clot that develops inside the veins of the leg

Despite the risks, surgery is often a clinical necessity to prevent life-threatening complications of pressure ulcers developing. Such complications include blood poisoning and gangrene (the decay or death of living tissue).

Caring for a Pressure Sore

Stage I or II sores will heal if cared for carefully. Stage III and IV sores are harder to treat and may take a long time to heal. Here’s how to care for pressure sore at home.

Relieve the pressure on the area.

  • Use special pillows, foam cushions, booties, or mattress pads to reduce the pressure. Some pads are water- or air-filled to help support and cushion the area. What type of cushion you use depends on your wound and whether you are in bed or in a wheelchair. Talk with your doctor about what choices would be best for you, including what shapes and types of material.
  • Change positions often. If you are in a wheelchair, try to change your position every 15 minutes. If you are in bed, you should be moved about every 2 hours.

Care for the sore as directed by your health care provider. Keep the wound clean to prevent infection. Clean the sore every time you change a dressing.

  • For a stage I sore, you can wash the area gently with mild soap and water. If needed, use a moisture barrier to protect the area from bodily fluids. Ask your provider what type of moisturizer to use.
  • Stage II pressure sores should be cleaned with salt water (saline) rinse to remove loose, dead tissue. Or, your provider may recommend a specific cleanser.
  • DO NOT use hydrogen peroxide or iodine cleansers. They can damage skin.
  • Keep the sore covered with a special dressing. This protects against infection and helps keep the sore moist so it can heal.
  • Talk with your provider about what type of dressing to use. Depending on the size and stage of the sore, you may use a film, gauze, gel, foam, or another type of dressing.
  • Most stage III and IV sores will be treated by your provider. Ask about any special instructions for home care.

Avoid further injury or friction.

Decubitus Ulcer

  • Powder your sheets lightly so your skin doesn’t rub on them in bed.
  • Avoid slipping or sliding as you move positions. Try to avoid positions that put pressure on your sore.
  • Care for healthy skin by keeping it clean and moisturized.
  • Check your skin for pressure sores every day. Ask your caregiver or someone you trust to check areas you can’t see.
  • If the pressure sore changes or a new one forms, tell your doctor.

Take care of your health.

  • Eat healthy foods. Getting the right nutrition will help you heal.
  • Lose excess weight.
  • Get plenty of sleep.
  • Ask your doctor if it’s OK to do gentle stretches or light exercises. This can help improve circulation.

Complications of Pressure Ulcer/ Bed Sores

Complications of bedsores, some of which are life-threatening, including

  • Cellulitis – Cellulitis is an infection of the skin and adjacent soft tissues. Symptoms can be warmth, redness, and swelling of the affected area.
  • Bone and joint infections – An infection from bedsore can invade into bones and joints. Joint infections (septic arthritis) can damage cartilage. Bone infections (osteomyelitis) can limit the function of the limbs.
  • Cancer –  Marjolin’s ulcers (long-term, non-healing wounds) can develop into a type of squamous cell carcinoma
  • Sepsis  – An untreated pressure injury can often lead to sepsis.
  • Dysreflexia,
  • Bladder distension,
  • Bone infection,
  • Synarthroses,
  • Sepsis,
  • Amyloidosis,
  • Anemia,
  • Urethral fistula,
  • Gangrene and very rarely malignant transformation (Marjolin’s ulcer – secondary carcinomas in chronic wounds).
  • Sores may recur if those with pressure ulcers do not follow recommended treatment or may instead develop seromas, hematomas, infections, or wound dehiscence.
  • Paralyzed individuals are the most likely to have pressure sores recur. In some cases, complications from pressure sores can be life-threatening. The most common causes of fatality stem from kidney failure and amyloidosis.

Other complication/risk factors for pressure sores include

  • immobility and paralysis – for example due to a stroke or a severe head injury
  • being restricted to either sitting or lying down
  • impaired sensation or impaired ability to respond to pain or discomfort – for example, people with diabetes who experience nerve damage are at increased risk of pressure sores urinary and fecal incontinence – skin exposed to urine or feces is more susceptible to irritation and damage
  • malnutrition – can lead to skin thinning and poor blood supply, meaning that skin is more fragile
  • obesity – being overweight in combination with, for example, immobility or being restricted to sitting or lying down, can place extra pressure on capillaries, reducing blood flow to the skin
  • circulation disorders – lead to reduced blood flow to the skin in some areas and can lead to pressure sores
  •  smoking – reduces blood flow to the skin and, in combination with reduced mobility, can lead to pressure sores. Healing of pressure sores is also a slower process for people who smoke.

People who use a wheelchair are most likely to develop a pressure sore on the parts of the body where they rest against the chair. These may include the tailbone or buttocks, shoulder blades, spine and the backs of arms or legs.

Prevention of Pressure Sores / Bed Sores

  • Change your position at least every 2 hours from your left side, to your back, to your right side.
  • In a wheelchair, shift your weight every 15 minutes. Use special foam or gel seat cushions to reduce pressure.
  • Choose clothing that isn’t too tight or so loose that it bunches up under you.
  • Protect other “pressure points” with pillows to help prevent new sores. If possible, use a pressure-reducing mattress or 3- to 4-inch foam layer over your mattress.
  • Exercise as much as possible. Try to take a short walk 2 or 3 times a day. If you can’t walk, pull up, and move your arms and legs up and down and back and forth.
  • Eat foods high in protein (such as fish, eggs, meats, milk, nuts, or peanut butter).
  • Increase fluids. (If you’re not eating well, try high-calorie liquids such as milkshakes or canned liquid food supplements.)
  • Always protect the sore and the area around it with a foam wedge or pillow.
  • Rinse any open sore with water very carefully and cover with a bandage. Do this every time the bandage gets soiled, or at least twice a day as instructed. If you’re given ointments or creams, use them as directed. Report any itching, blistering, new drainage, or increase in size of the sore to your cancer team.
  • Remind the patient to change positions often, or help the patient turn every 2 hours.
  • If the patient can’t control their bowels and bladder, change their underwear as soon as you notice soiling. After cleaning, apply an ointment (such as A+D ointment) to keep the area dry. Sprinkle cornstarch over the ointment. Use underpads to keep the patient from soiling the bed and to make it easier to clean up. Don’t use plastic underwear unless the patient is out of bed.
  • If the skin has an open sore, ask about special dressings to help protect it.

If the patient can’t get out of bed

  • Keep the bottom sheets pulled tight to prevent wrinkles.
  • Keep the head of bed flat or no higher than a 30° angle.
  • Sprinkle sheets with cornstarch to reduce friction from rubbing against them.
  • Check the patient’s back and sides each day to be sure that the skin looks normal. Pay special attention to pressure areas such as the tailbone, hipbones, knees, ankles, heels, shoulders, and elbows.
  • If you notice a reddened “pressure area” (an area that stays red after pressure is taken off it), keep the pressure off it as much as you can to try to prevent further breakdown. Use pillows and have the patient change position often.
  • If the patient has trouble staying on their side, ask about foam wedges to help hold positions.
  • Ask your cancer team if you can get a home health nurse to visit and help you make a plan to care for and prevent further skin problems.
  • Ask if you can get foam, gel, or air cushions for the bed and chairs. Find out about special beds that help reduce pressure.

When a person is bedridden, pressure sores can occur in a number of areas, including

  • back or sides of the head
  • rims of the ears
  • shoulders or shoulder blades
  • hipbones
  • lower back or tailbone
  • backs or sides of the knees
  • heels, ankles, and toes.

References

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