Natural History, Systemic Effects and Complications of Pressure Ulcers and the Management of the Wou

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Natural History, Systemic Effects and
Complications of Pressure Ulcers and the
Management of the Wounded Patient
George Taler, MD Director, Long Term
Care Washington Hospital Center Medical
Director Northwest Healthcare Center Washington,
DC
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Summary

• The Etiology of Tissue Injury in PU
• - Cutaneous injury
• - Sub-cutaneous injury
• Systemic Implications of Pressure Ulcers
• Holistic Approach to the Wounded Patient
• Implications of the Non-healing Wound

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Pressure Ulcer Staging

• Stage 1Non-blanchable erythema of intact skin,
  or induration over bone
• Stage 2Partial thickness
• Stage 3Full thickness into subcutaneous tissues,
  but not through fascia
• Stage 4Full thickness with extensive destruction
  of underlying tissues
• Unstageable Eschar and DTI

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Young
Old
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Superficial v Deep Pressure Ulcers

• Superficial
• - Shear Pressure
• - WYSIWYG
• - Local trauma
• - Treatment topical
• - Heal by tissue regeneration
• - High healing rate

• Deep
• - Pressure Shear
• - Initial injury hidden
• - Systemic impact
• - Treatment systemic
• - Heal by secondary intent and scarring
• - Low healing rate

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Superficial v Deep Pressure Ulcers

• Superficial
• - Shear Pressure
• - WYSIWYG
• - Local trauma
• - Treatment topical
• - Heal by tissue regeneration
• - High healing rate

• Deep
• - Pressure Shear
• - Initial injury hidden
• - Systemic impact
• - Treatment systemic
• - Heal by secondary intent and scarring
• - Low healing rate

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Systemic Effects of Pressure Ulcers

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Systemic Effects of Pressure Ulcers

• Depletion of visceral protein stores
• Increased cortisol levels
• Increased adrenergic hormone levels

• Laboratory evidence of protein malnutrition
• Potential deterioration in immune capacity
• Deterioration in glucose control
• Deterioration in heart failure

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Evaluation andMedical Management ofthe Wounded
Patient
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Medical ManagementSummary

• Establish goals and objectives
• Pressure relief
• Nutritional support
• Dressings
• Infection Control
• Control co-morbid conditions

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Medical ManagementEstablish Goals and Objectives

• Treatment plans must be consistent with the
  values, goals and expectations of the patient,
  family and caregivers.

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Medical ManagementPressure Relief

• Support surfaces
• Passive Foam, gel and air mattresses
• Dynamic APP, low air-loss, air-fluidized
• Positioning
• Regular turning and repositioning
• Padding over and between boney prominences
• No donuts
• Lifting devices

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Medical ManagementNutritional Support

• 30-35 cal / kg / d IBW
• 1.5-2.5 gm protein / kg / d IBW
• 40 cc fluids / kg / d IBW
• Micro-nutrients
• Zinc
• Vitamin C
• Omega-3 oil

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Medical ManagementNutritional Support

• Fortify protein
• Egg whites
• Powered milk
• Fortify calories
• Ice cream
• Chocolate bars (3 Musketteers, Milky Way)
• Sugar syrup

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Orexogenic Medications

• Mirtazapine (Remeron)
• Treats depression.
• 75/mo
• Dronabinol (Marinol)
• Insufficiently studied in the frail elderly.
  (360/mo)
• Oxandrolone (Oxandrin)
• Anabolic steroid
• Requires exercise to ? muscle mass. (250-1000/
  1mo course)

• Megestrol acetate (Megace)
• Some pts gain, others lose
• ? risk of phlebitis, PE, DM
• 2-3 mos. to assess efficacy
• No data on whether weight gain improves patient
  outcomes
• 330/mo

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Medical ManagementControl Co-morbid Conditions

• Pain control
• Optimize immune function
• Malnutrition
• Diabetes
• Renal insufficiency
• Thyroid disease
• Reduce steroids and anti-inflammatory drugs
• Depression

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Medical ManagementControl Co-morbid Conditions

• Optimize tissue oxygenation and perfusion
• Congestive Heart Failure
• Emphysema / Bronchitis
• Peripheral Vascular Disease

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Medical ManagementInfection v Colonization

• All wounds are colonized
• Topical antibiotics increase risk of
• Allergic sensitivities
• Bacterial resistance
• Treat cellulitis
• According to deep tissue biopsy cultures
• Empirically

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Wound Assessment and Local Care
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Wound Assessment

• Skin integrity
• Nature of the wound base
• granulation/re-epithelialization
• slough
• necrosis/eschar
• undermining /tunneling
• Amount of exudate
• Surrounding tissues

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Medical ManagementCleansing the Wound Bed

• Normal saline
• Commercial skin cleansers
• Expensive
• Interfere with leukocyte migration
• Iodine toxicity
• Mild soap and water

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Medical ManagementDebridement of the Wound Bed

• Sharp
• Pickers necrotic tissue (no blood)
• Hackers cut to vital tissue (like a stuck pig)
• Mechanical
• Wet-to-dry dressings
• Whirlpool / Pulse-lavage
• Enzymatic collagenase or papain/urea
• Autolysis occlusive dressings

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Medical ManagementDressings

• Protect the wound bed
• Trauma
• Contamination
• Absorb excess wound exudate
• Maintain a moist healing environment
• Granulation tissue fibrocytes and angiocytes
• Occlusive dressings
• (Restore inflammatory/growth factors)

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The Affects of Dressings on the Healing of Wounds
Currently available dressings do not accelerate
healing, they primarily prevent delay in the
normal processes

• Moist environment
• The future of topical interventions

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The Wide Array of Wound Care Products

• 1 Dressings against the wound bed
• 2 or fillers or absorbing layer
• Cover dressing

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Wound Care Products 1 Dressings

• Exudate absorbing products
• Min hydrocolloid, gauze
• Mod alginates, fluffed gauze, foam
• Copious alginates, foam, fluffed gauze
• Hydrating products
• Hydrogel wafers or pastes
• Debriding agents
• Collagenase
• Papain/urea

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Wound Care Products 2 or Fillers or Absorbing
Layer

• For wounds with depth 5 mm, and
• Moderate to copious exudate
• Products
• Alginates
• Foams
• Moistened fluffed gauze wrap or 4x4
• Wound filler pads

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Wound Care ProductsCover Dressings

• Maintain a moist wound environment
• Hold the underlying layers in place
• Prevent contamination and trauma
• Products
• Transparent films
• Hydocolloid dressings
• Island dressings

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Complications of Pressure Ulcers
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Summary
Systemic
Local

• Pain
• Cellulitis
• Osteomyelitis
• Septic arthritis
• Hygiene problems
• Loss of joint integrity

• Loss of I/ADL
• Depression
• Nutrient depletion
• Impaired healing
• Sepsis
• Mortality

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Local Complications

• Pain
• Superficial pain (skin receptors)
• Sharp, burning, intense usually associated with
  care
• Wound cleansing choices
• Dressing choices
• Deep pain (periostial and joint space receptors)
• Dull, aching, chronic discomfort
• Dulls affect and motivation
• Systemic therapies

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Local Complications cont.

• Local infections
• Cellulitis
• Osteomyelitis local and metastatic
• Septic Arthritis
• Loss of joint integrity
• Loss of function
• High risk of amputation

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Cellulitis in a Healing Wound
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Local Complications cont.

• Hygiene
• Exudate
• Odor

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Systemic Complications

• Loss of ADL and IADL functions
• ADL personal care
• IADL community independence
• Depression
• Anorexia with weight loss
• Loss of motivation in rehabilitation
• Decreased self-care and hygiene

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Systemic Complications cont.

• Nutrient depletion
• Caused by acute inflammatory processes
• Diminished energy stores
• Physical
• Emotional
• Impaired healing
• Increased risk of infection / sepsis
• Up to a 4X increased rate of mortality

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Death
Causative of?
Associated With ?
Pressure Ulcers
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Thank You
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Treatment Intact skin

• Preventive measures
• No dressings needed
• Monitor frequently

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Treatment Clean Wound Base

• Preventive Measures
• Maintain a moist wound bed while keeping
  surrounding skin dry
• Fill dead-spaces with loosely packed dressing
  material for absorption of exudates

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Treatment Slough or Eschar

• Preventive Measures
• Debridement (except dry eschar on heels)
• Avoid topical antiseptics
• Maintain a moist wound bed while keeping
  surrounding skin dry
• Fill dead-spaces with loosely packed dressing
  material for absorption of exudates

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Treatment Extensive Damage

• Preventive Measures
• Debride devitalized tissue and unroof undermined
  areas dry pack for 8-24 hrs.
• Maintain a moist wound bed while keeping
  surrounding skin dry
• Fill dead-spaces with loosely packed dressing
  material for absorption of exudates

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PU ? Mortality
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• Is the PU indicative of just another organ system
  failure in a cascade of failures?
• What was the prognosis prior to the onset of the
  PU? Did it change thereafter?
• What was the risk of PU? Were preventive measures
  compromised due to extenuating circumstances?