Pressure sore management

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Pressure sores are localized areas of tissue breakdown in skin and/or underlying tissues that develop when persistent pressure between a bony site and underlying surface obstructs healthy capillary flow. Constant external pressure over 70 mm Hg for 2 hours produces irreversible ischemic changes. Synonyms : Pressure ulcer, Decubitus ulcer, Bed sore.

Transcript of Pressure sore management


2. PRESSURE SORE Pressure sores are localized areas of tissue breakdown in skin and/or underlying tissues that develop when persistent pressure between a bony site and underlying surface obstructs healthy capillary flow. Constant external pressure over 70 mm Hg for 2 hours produces irreversible ischemic changes. Synonyms : Pressure ulcer, Decubitus ulcer, 3. Patient Populations at High Risk Paraplegic or tetraplegic patients Patients with decreased sensation due to neurologic disorders, e.g. stroke. Patients with impaired mental capacity. Seriously ill patients in an intensive care unit. Additional Risk Factors Malnutrition Incontinence Tobacco use. 4. Areas Prone to the Development of Pressure Sores More common Scrum Trochanter Ischial tuberosity Less common Calcaneum Malleolus Scapula Elbow Knee 5. Patients Admitted with Pressure Sore at CRP on 2007 Total patients : 415 Total patients with pressure sore : 173 (30% of total) Male patients with pressure sore : 157 (27%) Female patients with pressure sore : 16 (3%) Sex distribution among pressure sore patients on 2007 Female 3% Male 27% Total 70% 6. Pressure Sore Staging System Stage I : Redness of intact skin that does not blanch. Stage II : Partial-thickness skin loss involving the epidermis and dermis. Stage III : Full-thickness skin loss involving the underlying subcutaneous fat but not the muscle. Stage IV : Full-thickness skin loss with extensive destruction, tissue necrosis, or damage in muscle, bone, or supporting structures. 7. Treatment of STAGE I and II Pressure Sore Keep the affected tissue clean and the surrounding area dry by regular daily dressing. Apply antibiotic ointment (e.g., Bacitracin, silver sulfadiazine) daily to areas that have blistered. 8. Treatment of STAGE III and IV Pressure Sore If the wound has a red, granulating base : Apply saline dressing daily. If the wound contains necrotic tissue : - Surgical debridement is necessary. - Follow with daily dressings, using saline or EUSOL solution. If the wound is infected : - Treat the patient with a course of antibiotics. - Twice daily dressing with Betadine solution. 9. Dressing Materials Normal Saline Betadine solution EUSOL solution Spirit Betadine ointment 10. Out come of Regular Wound Dressing On Admission Two months later 11. Surgical Intervention Wound Debridement Skin Grafting Plastic surgery 12. Wound Debridement When a wound is covered with black, dead tissue or thick gray/green exudates, surgical removal of necrotic tissue is needed. Dead bone or tendon in the wound must be removed. Bleeding tissue is a good sign healthy tissue. Dead tissue does not bleed. Once the necrotic tissue has been removed, regular Wet-to-dry dressing should be started. 13. Out Come of Debridement and Dressing Before After 14. Skin Grafting Cross-section of human skin showing the epidermis, dermis and subcutaneous tissue. The relative thickness of skin grafts is shown. 15. Split-thickness Skin Graft Indications : Large wound (> 56 cm in diameter) that would take many weeks to heal secondarily. Wounds that cannot be closed primarily. Wounds that require more stable coverage than scar. Contraindications : Malnourished patient. Necrotic tissue or signs of infection at the wound A wound that has exposed tendon or bone. 16. Skin-graft (Humby) knife Harvesting a split-thickness graft with the Humby knife. Wound covered with a split-thickness skin graft. 17. Skin Grafting at Sacral Pressure Sore Preoperative Postoperative Two months before surgery 18. Plastic Surgery End to end closure Flaps Pre requisites of plastic surgery : Excellent nutritional status. Albumin > 3.5 gm/dl, Prealbumin > 20mg/dl, Transferrin > 250 mg/dl (2.5 gm/L). The patient must not smoke. Patients should be motivated enough to change positions regularly. 19. End to End Closure Preoperative Postoperative 20. End to End Closure Preoperative Postoperative 21. FLAP A flap is a piece of tissue with a blood supply that can be used to cover an open wound. A flap can be created from skin with its underlying subcutaneous tissue, fascia, or muscle. Flap Local Flap Distant Flap Skin Flap Muscle Flap Axial Flap Random Flap 22. Random Flaps Circulation to a random flap is provided in a diffuse fashion through tiny vascular connections from the pedicle into the flap. The pedicle must be bulky to increase the number of vascular connections. The flap should not be longer than 3 times its width. Random skin flap. The blood supply comes diffusely from the remaining skin attachment, which serves as the pedicle. 23. Different Types of Random Flaps Rhomboid flap Rotation flap Tensor fascia lata (TFL) flap V-Y advancement flap. Rectangular advancement flap. 24. Rhomboid Flaps Rhomboid flaps are useful for wounds up to 6 to 8cm in diameter on the trunk or extremity. Useful in pressure sores with less surrounding tissue laxity. 25. Rhomboid Flaps Preoperative 5th Postoperative day 15th Postoperative day 26. Rhomboid Flaps Pre-operative Pre-operative 10th Post-operative day15th Post-operative day 27. Rhomboid Flaps Pre-operative 7th Post-operative day One month later 28. Rhomboid Flaps Per-operative pictures 29. Buttocks Rotation Flap Most commonly used for sacral pressure sore. Useful for sacral wounds about 10 to 12cm in diameter. 30. Bilateral Rotation Flap Pre-operative Per-operative 31. Bilateral Rotation Flap Per-operative pictures 32. Tensor Fascia Lata (TFL) Flap TFL flap is the most commonly used for closure of trochanteric pressure sore. The flap is composed of the skin and fascial extension from the TFL muscle. 33. Tensor Fascia Lata (TFL) Flap Pre-operative Post-operative 34. Tensor Fascia Lata (TFL) Flap Pre-operative Per-operative 35. Tensor Fascia Lata (TFL) Flap Per-operative pictures 36. General Post Operative Care Cleanse and apply antibiotic ointment to the suture lines daily. If a suction drain was used, it should stay in place at least 1 week. The patient should apply no pressure to the surgical site until the suture line has healed (usually 23 weeks). Leave the skin sutures in place for at least 14 days unless there are signs of irritation from the sutures. 37. Failure of Flap surgery Ischemic flap necrosis. Infection. Haematoma. Recurrence of pressure sore at surgical site. 38. Graphical Presentation of Pressure Sore surgeries from Jan07 to Apr08 Skin Grafting Plastic Surger 1 9 5 13 5 5 8 20 0 2 4 6 8 10 12 14 16 18 20 Jan'07 - Apr'07 May'07 - Aug'07 Sep'07- Dec'07 Jan'08- Apr'08