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Pressure Sores
高雄榮總整形外科朱俊旭 醫師
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Introduction
• Treatment of pressure sores remains a significant challenge to the medical community.
• Team works: physicians ( PS, GS, Ortho, Internal medicine, endocrinology, and neurology ), nurses, nutritionists, mental health experts.
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Definition
• Pressure sore, decubitus ulcer, bedsore
• Unrelieved pressure, altered sensory perception, incontinence, exposure to moisture, altered activity and mobility, friction, and shear force.
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TABLE 1. Pressure sore staging
Stage Description .
Stage I Skin intact but reddened for more than 1 hour after
relief of pressure
Stage II Blister or other break in dermis ± infection
Stage III Subcutaneous destruction into muscle ± infection
Stage IV Involvement of bone or joint ± infection
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Cone shaped pattern of injury resulting from unrelieved pressure. The highest pressure and greatest injury is deep , adjacent to the bone. The cutaneous wound is only the “ tip of the iceberg.”
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Epidemiology
• In general, approximately 9% of all hospitalized patients develop pressure sores.
• In paraplegic patients: ischial, trochanteric and sacral regions --- most common sites.
• In acute care patients with bedridden: sacral (36%), heel (30%), and ischial-trochanteric-malleolar(6%)
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Pathophysiology (1)
• Extrinsic factors: pressure, shear, friction.
• Intrinsic factors: local ischemia, fibrosis, diminished autonomic control, infection, patient age, sensory loss, impaired mobility, decreased mental status, fecal or urinary incontinence, small vessel occlusive disease, anemia, and hypoproteinemia.
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Pathophysiology (2)
• Infection: compressed skin has less resistance to bacterial invasion.
• Edema: the result of inflammatory mediators released in response to the trauma of compression.
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Preoperative Care (1)
• Nutrition: nonprotein calories 25-35cal/kg; protein 1.5 to 3.0 gm/kg per day.
• Vitamins A & C
• Zinc: epithelization and fibroblast proliferation
• Ca2+ , Fe2+
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Preoperative Care (2)
• Infection control: the most common organisms cultured from pressure sores include common skin flora (Staphylococcus, Streptococcus, Corynebacterium) and enteric organisms (Proteus, E.coli, and Pseudomonas).
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Preoperative Care (3)
• Relief of Pressure: turning the patient at intervals (change position q2h)
• Spasm treatment: Spasticity (spinal cord injury), 100 % in C-spine injury, 75% in T-spine injury, 50% in L-spine injury.
• Valium 10 mg q8h, baclofen 10 mg q6h, Dantrolene 25 mg iv. q12h
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Surgical Treatment
• Three principles:
(1) Excisional debridement of the ulcer
(2) Partial of complete ostectomy to reduce the bony prominence
(3) Closure of the wound
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Ischial pressure sore
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Pressure sore closure
• Musculocutaneous flaps: excellent blood supply, provision of bulky padding, against infection
• Fasciocutaneous flaps: adequate blood supply, durable coverage, minimal functional deformity
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Complication
• Recurrence: the most common complication associated with pressure sore reconstruction.
• Carcinoma:
(1) In 1828, Jean Nicholas Marjolin --- a tumor was present in a chronic wound.
(2) Dupuytren proved it as a malignancy.
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Marjolin’s ulcer
• Carcinoma arising in a chronic wound.
• SCC--- the most common cell type
• Their metastatic rate, as compared to that of Marjolin ulcers arising in burn scars, is significantly higher at 61 % versus 34%.
• More aggressive, poor prognosis
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