Pressure Sores

高雄榮總整形外科朱俊旭 醫師

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.

Definition

• Pressure sore, decubitus ulcer, bedsore

• Unrelieved pressure, altered sensory perception, incontinence, exposure to moisture, altered activity and mobility, friction, and shear force.

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

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.”

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%)

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.

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.

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+

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).

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

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

Ischial pressure sore

Pressure sore closure

• Musculocutaneous flaps: excellent blood supply, provision of bulky padding, against infection

• Fasciocutaneous flaps: adequate blood supply, durable coverage, minimal functional deformity

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.

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