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Management
Pharmacological
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Pain management. Pressure ulcers can be painful. Nonsteroidal antiinflammatory drugs such as ibuprofen (Motrin IB, Advil, others) and
naproxen (Aleve, others) may reduce pain. These may be very
helpful before or after repositioning, debridement procedures and
dressing changes. Topical pain medications also may be used during
debridement and dressing changes.
WOUND CARE
The purpose of local wound care is to provide the wound with the most
optimal environment for healing. Specific factors that need to be taken into
consideration are:
Level of moisture: the provision of a moist healing environment has been
accepted to be the standard of care in pressure ulcer management. It is
believed that wound healing is optimized at an appropriately moist
environment, while a dry or excessively moist environment will be
detrimental to wound healing. Depending on the pre-existing level of
moisture in the wound bed, various dressings can be used to correct the
level of moisture in the wound. The different types of dressings are
discussed under GENERAL DRESSING GUIDELINES.
Debridement of necrotic tissues: the removal of necrotic tissues, eschar, and
slough is a well-accepted practice in wound bed preparation for healing.
These devitalized tissues may support the proliferation of pathogens.
Though debridement is widely practiced, there has not been any substantial
research study on this topic. There are four methods by which debridement
can be achieved. In the order of their onset of action, with the most rapid
onset being first, they are: sharp debridement with scalpel or scissors,
nonselective mechanical debridement through the use of irrigation or a wetto-dry dressing, chemical debridement through the use of an enzyme such
as collagenase without damage to the granulation tissues, and autolytic
debridement
Wound cleansing: wound cleansing facilitates the removal of necrotic materials,
exudates any metabolic wastes away from the wound, thus promoting
wound healing. It also may decrease the bacterial load in the wound tissue;
this is important because a bacterial count of greater than may be
associated with the development of wound infection
Electromagnetic Therapy
There is growing interest in the use of electromagnetic therapy for the
treatment of pressure ulcers. This modality has been shown to increase the
blood flow, collagen formation, and also granulocyte infiltration in both in
vitro and animal models to induce healing. However, clinical trial evidence is
again lacking.
I.MANAGEMENT
A. PHARMACOLOGICAL MANAGEMENT
1. Pain management
- Interventions that may reduce pain include the use of nonsteroidal antiinflammatory drugs such as ibuprofen (Motrin, Advil, others) and naproxen
(Aleve, others) particularly before and after repositioning, debridement
procedures and dressing changes.
- Topical pain medications, such as a combination of lidocaine and prilocaine, also
may be used during debridement and dressing changes.
2. Antibiotics
- Pressure sores that are infected and don't respond to other interventions may be
treated with topical or oral antibiotics.
3. Healthy diet with Vitamins
- Appropriate nutrition and hydration promote wound healing.
- Increase in calories and fluids, a high protein diet, and an increase in foods rich
in vitamins and minerals.
- Dietary supplements, such as vitamin C and zinc.
4. Muscle spasm relief
- Muscle relaxants such as diazepam (Valium), tizanidine (Zanaflex), dantrolene
(Dantrium) and baclofen may inhibit muscle spasms and enable the healing of
sores that may have been caused or worsened by spasm-related friction or
shearing.
B. SURGICAL MANAGEMENT
INDICATIONS FOR SURGERY
Musculocutaneous flaps are usually the best choice for stage 4 pressure ulcers
of the buttocks4 in spinal cord-injured patients, or when the concomitant loss of
muscle function does not contribute to comorbidity. Tissue expanders might
optimize.
SKIN GRAFT
A skin graft is a patch of skin that is removed by surgery from one area of the
body and transplanted, or attached, to another area.
Healthy skin is taken from a place on your body called the donor site. Most
people who are having a skin graft have a split-thickness skin graft. This takes
the two top layers of skin from the donor site (the epidermis) and the layer under
the epidermis (the dermis).
Bleeding
Chronic pain (rarely)
Infection
Loss of grafted skin (the graft not healing, or the graft healing slowly)
Scarring
Skin discoloration
The diabetic foot has deformities that predispose to ulceration. If the ulcer heals
and then recurs several times, the orthopedic or podiatric surgeon should
evaluate the patient for foot reconstruction, osteotomies, or tendon recessions.
REVASCULARIZATION
The purpose of local wound care is to provide the wound with the most optimal
environment for healing. Specific factors that need to be taken into consideration
are:
a. Level of moisture:
Purposes of Debridement
Methods of Debridement
a. Autolytic Debridement
Use of endogenous enzymes of the body to debride necrotic
tissue
Use of moisture retentive or moisture donating dressing
Safe, non-invasive, does not disrupt healthy tissue
Indications: necrotic tissue, dry eschar
Contraindications: dry gangrene, ischemic wound, poor
circulation
Dressings that promote autolysis: thin films, hydrocolloids,
hydrogels, alginates, semi-permeable foams
b. Enzymatic Debridement
The use of topical applied chemical agents to stimulate the
breakdown of necrotic tissue
Common topical agents: collagenase, fibrogen, papain/ urea
c. Sharp Debridement
It is the most effective and most rapid type of debridement
It is the use of scalpel, forceps, scissors or lasers to remove
dead tissue
It is used for large amount of necrotic tissue
Indications: extensive devitalized tissue, advancing cellulitis,
thick and adherent eschar
Contraindications: arterial insufficiency, excessive bleeding,
immunocompromised
d. Mechanical Debridement
It is used for moderate amount of necrotic tissue
It is the use of dressings like gauge
e. Biological Debridement
Maggot Therapy
Indications:
All types of wound problems
Surgical or other types of debridement are difficult, risky o not
available
Other conditions like osteomyelitis, burns, abscesses,
nerotising fasciitis
Preparation for grafting
Contraindications:
Absolute: fistula, wound connected to body cavity, rapid
advancing tissue necrosis
Relative: exposed vessel, bleeding tendency, difficult
dissolving tissue
Advantages:
Effective
Selective
Simple
Rapid
Universally usable
Kills bacteria
May increase healing
Disadvantages:
The ethical aspect
Requires some skill
Maybe expensive
Can cause pain
Not available in all place
c. Wound cleansing:
d. Protection of wounds:
OF PRESSURE
ULCCER
INDICATION
GAUZE Dry
Scabbed
over
dressing
wounds
WetStage
III,
IV
to-dry
pressure
ulcers
with
necrotic
materials
Wet-toStage
III,
IV
moist
pressure sore
OCCLUSIVE
Stage I, II pressure
transparent film ulcers
with
no
dressings
that drainage
are
semipermeable
GEL hydrophilic Stage II, III, IV
polymer
that pressure
ulcers
comes in a sheet, with little to no
granules
or drainage
liquid gel forms
HYDROCOLLOID Stage
II
(III)
pressure
ulcers
dressings
containing
gel- with little to great
forming
agents drainage
(e.g.
sodium
carboxymethylce
llulose
and
gelatin),
often
combined
with
elastomers
and
adhesives
applied
to
a
carrier
FOAM
polyurethane
dressing
that
comes in sheets
or fillers
ALGINATES
highly
absorbent,
biodegradable
MECHANISM
ACTION
OF POTENTIAL
ADVERSE EFFECT
Physical barrier
Mechanical
debridement,
absorbent
Provide
moist
healing
environment
Nonselective, may
remove granulation
tissue
May dry out and
turn into wet-to-dry
dressing
Physical
barrier, Excessive moisture
moisture retention, retention of wound
promote autolytic drains excessively
debridement
Provide
moist
healing
environment,
promote autolytic
debridement
Occlusive
and
adhesive
wafer
dressing that forms
a
gel-like
substance
with
wound
exudate,
promoting
moist
healing
and
autolytic
debridement
Provide
moist
healing
environment,
promote autolytice
debridement
Stage
III,
IV Absorb
excessive
pressure
ulcers exudates, promote
with moderate-to- autolytic
great drainage
debridement
dressings
derived
from
seaweed
MATRIX
Stage
III,
collagen matrix pressure ulcers
that
provides
threedimensional
scaffolding
attracts
host
cells and tissue
remodeling
IV Promote
granulation
and
epithelialization
into the matrix
ES has been used for the treatment of chronic wounds for many years (128) and
has been specifically recommended for the treatment of severe (Grade III or IV)
pressure ulcers.
ES to be an effective modality; however, the specific treatment and stimulation
paradigms employed were found to be highly variable. The mechanisms by
which ES promotes wound healing are not fully understood, leading to a need to
optimize delivery of treatment.
Negative pressure wound therapy (NPWT) is based on the theory that the
negative pressure facilitates drainage of wound exudates and enhances
wound healing through a number of mechanisms. NPWT is proposed to
decrease the bacterial load and edema while concurrently promoting an
improved local circulation and increasing granulation. NPWT devices consist
Utility is suggested for traumatic acute wounds especially with skin grafts
or skin flaps, open amputations, lower extremity fasciotomy, open
abdomen, etc.
Appears to increase burn wound perfusion and limit burn wound
progression
THERAPEUTIC ULTRASOUND
ELECTROMAGNETIC THERAPY
POSITIONING
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Foam: A thick slab of foam with a textured surface placed on top of a standard
mattress to reduce pressure by surrounding the body; should be at least 34
inches thick to be effective at reducing pressure (2 inches is for comfort only)
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Water: A vinyl mattress or overlay with sections filled with water to distribute
pressure more evenly and create a flotation effect
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Gel: Made of a thick fluid that conforms to the contours of the body
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Air-fluidized: Uses a high rate of blown air to fluidize fine particulate material (such as silicone
beads) to float the patient on the surface