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林明憲醫師 台北榮總高齡醫學中心 國立陽明大學醫學系 103.09.13. - PowerPoint PPT Presentation


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壓瘡. 林明憲醫師 台北榮總高齡醫學中心 國立陽明大學醫學系 103.09.13. Definition. Any lesion caused by unrelieved pressure resulting in damage of underlying tissue

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slide1

壓瘡

林明憲醫師

台北榮總高齡醫學中心

國立陽明大學醫學系

103.09.13.

definition
Definition

Any lesion caused by unrelieved pressure resulting in damage of underlying tissue

Areas of local tissue trauma, usually developing where soft tissues are compressed between bony prominences and any external surface for prolonged time periods

slide3
A sign of local tissue necrosis

Most commonly found over bony prominences subjected to external pressure

Most common locations: sacrum, ischial tuberosities, trochanters and heels

sacrum and heels most frequent

Synonymous terms

Pressure ulcer

Decubitus ulcer

Bedsore

epidemiology
Epidemiology

Prevalence

Hospitalized elderly: 15%

Patients expected to be bedridden or chair bound > 1 week, ≥ stage II pressure ulcers: 28%

Prevalence varies by setting

Nursing home = 2.3% to 28%

Home care = 6% to 9%

Outpatient clinic = 1.6%

epidemiology1
Epidemiology

Incidence

Incidence during hospitalization: 8~30%

Timing: first 2 weeks of hospitalization

The first 5 days in critical care unit

Highest incidence rate: orthopedic population (9-19%); quadriplegic (33-60%)

morbidities associated with pressure ulcers
Morbidities associated with pressure ulcers

Pain

Disfigurement

Septicemia

Prolonged hospitalization

Increased death rates

quality issues

morbidities associated with pressure ulcers pain
Morbidities associated with pressure ulcers- Pain
  • Pain
    • 87% at dressing changes
    • 84% at rest
    • 42% both
    • 18%: pain when CD, the highest level
    • Only 6% of them received analgesics
    • Stage III~IV > stage II pain? (some evidence)
morbidities associated with pressure ulcers septicemia i
Morbidities associated with pressure ulcers- Septicemia (I)
  • Most severe complication
  • Incidence 1.7/10,000
  • Overall mortality 48%: if pressure ulcer is the source
  • Transient bacteremia after debridement: 50%
  • Infectious complication
    • Wound infection
    • Cellulitis
    • Osteomyelitis
morbidities associated with pressure ulcers septicemia ii
Morbidities associated with pressure ulcers- Septicemia (II)
  • Among patients with nonhealing or worsening pressure ulcers
    • 26% have underlying bone pathology, osteomyelitis
    • 88% are colonized Pseudomonas aeruginosa
    • 34% with Providencia species
    • Either pathogen should not be considered typical colonization
    • Can be reservoirs for antibiotic-resistant bacteria
morbidities associated with pressure ulcers death rate
Morbidities associated with pressure ulcers- Death rate
  • Death rate among bed- or chair-bound patients
    • 60% (PU+) vs 38% (PU-) 1 year after discharge
  • Nursing home resident whose pressure ulcers healed within 6 months or not
    • Mortality: 11%(PU healed) vs. 64%(PU not healed)
  • Mortality rate : 3.8 per 100,000 population
    • Marker for coexisting morbidity
morbidities associated with pressure ulcers q uality issue
Morbidities associated with pressure ulcers- Quality issue
  • Pressure ulcer incidence and severityare used as markers of quality care
    • long-term care facilities
    • home care agencies
    • acute care hospitals
  • Evaluate:
    • Each patient upon admission
    • Regularly thereafter for high risk group
pathophysiology
Pathophysiology

Pressure ulcers are the result of mechanical injury to the skin and underlying tissues.

4 factors

Pressure

Shearing force

Friction

Moisture

pressure
Pressure

Perpendicular force or load exerted on a specific area, causing ishcemia and hypoxia of the tissues

Muscle and subcutaneous tissues are more sensitive than epidermis

High pressure area:

Supine: occiput, sacrum, heels

Sitting: ischial tuberosities

Sidelying: Trochanters

pressure need to impair tissue perfusion
Pressure need to impair tissue perfusion
  • Closing pressures
    • Arteriole - 32 mm Hg
    • Venule - 15 mm Hg
    • Capillary pressure - 25 mm Hg
  • > 32 mmHg pressure would cause tissue ischemia
pressure1
Pressure

Pressure under bony prominence, ex:

Buttock in lying position: 70mmHg

Sacrum and greater trochanter: 100-150mmHg

In seated persons, ischial tuberosities: 300mmHg

Factors lower the threshold

Repeated exposures to pressure

Loss of subcutaneous tissue

shearing forces
Shearing forces

Lower the amount of pressure required to cause damage to epidermis

Decrease the amount of pressure required to occlude blood vessels

Tangential forces, ex: sliding

Important in development of deep tissue injury

friction and moisture
Friction and Moisture

Friction

Cause intraepidermal blisters

Superficial erosions

Moisture

Directly lead to maceration and epidermal injury

Impact on friction forces

assessment
Assessment

Risk assessment

Assessment of pressure ulcer stage

Assessment of pressure ulcer healing

risk assessment factors
Risk Assessment- Factors
  • Immobility or severely restricted mobilitybeing the most important risk factors
    • >50 vs <20 movements at night: 0% vs 90% PU occurence
  • Incontinence (Fecal > urine incontinence)
  • Malnutrition
  • Impaired mental status
  • Altered sensation or response to pain and discomfort
  • Increased body temperature
  • Decreased blood pressure
  • Advanced age
risk assessment interval
Risk Assessment - Interval
  • Acute care hospital:
    • Every 48Hrs
  • Home health setting:
    • Weekly for 4 weeks, followed by every other week
  • Nursing home resident:
    • Weekly for 4 weeks, followed by quarterly assessment
risk assessment tool i
Risk Assessment – Tool (I)
  • Norton scale
    • Oldest, developed in 1961, in England
    • 5 subscales: physical condition, mental state, activity, mobility, incontinence,
    • Each scale 1-4, total score 5-20
    • ≤16/20: onset of risk
    • ≤12/20: high risk
risk assessment tool ii
Risk Assessment – Tool (II)

Braden scale

Developed in 1987, in USA

6 subscale: sensory perception, moisture, activity, mobility, nutrition, friction and shear

Each scale 1-4, except friction and shear 1-3

Total score 6-23

≤16/23: at risk

15-16/23: mild risk, 50~60% risk for stage I PU

12-14/23: moderate risk, 65-90% risk for stage I or II PU

<12: high risk, 90~100% risk for stage II or deeper PU

slide24

Braden壓瘡危險因子評估表

註:分數≧16分(低危險):每日皮膚評估一次。

分數12~15分(中等危險):皮膚評估+每2小時翻身拍背一次。

分數≦11分(高危險):皮膚評估+每2小時翻身拍背一次+氣墊床使用。

slide25
壓瘡風險評估工具之臨床效度
  • 橫斷式之調查法,在台灣地區北部、中部、南部及東部,各依人口分佈分層抽樣選取2,631住院病人為收案對象。

于博芮、李世代、林壽惠:台灣醫療院所壓瘡風險評估工具之臨床效度。台灣老年醫學雜誌 2005;1:79-88。

assessment of pressure ulcer stage
Assessment of Pressure Ulcer Stage
  • Grading or staging system based on observable depth of tissue destruction
  • Initial assessment: deepest layer of tissue involved
  • Mostly common used :
    • National Pressure Ulcer Advisory Panel’s (NPUAP) classification system
    • (美國國家壓瘡諮詢委員會)
staging
Staging

NPUAP (National Pressure Ulcer Advisory Panel) 2007

Stage I: Nonblanchable erythema

Intact skin, usually over a bony prominence

Stage II: Partial thickness skin loss

Invulving epidermis and/or dermis

Stage III: Full thickness skin loss

Extend into subcutaneous tissues to deep fascia, but bone, tendon, or muscle not exposed

Stage IV: Full thickness tissure loss

Exposed bone, tendon, or muscle

staging1
Staging

Unstagable/Unclassified: Full thickness skin or tissue loss– depth unknown

Full-thickness injury

Actual depth obscured by slough and/or eschar

Cannot be staged until removed

Suspected Deep Tissue Injury– depth unknown

Purple or maroon localized area of discolored intact skin or blood-filled blister

due to damage of underlying soft tissue from pressure and/or shear

assessment of pressure ulcer healing
Assessment of Pressure Ulcer Healing
  • At a minimum:
    • Location
    • Depth and Stage
    • Size
    • Wound bed description:
      • necrotic tissue, exudate,
      • wound edges for undermining and tunneling,
      • presence or absence of granulation and epithelialization
  • Follow-up assessment: at least weekly
  • Two research-based pressure ulcer assessment tools
    • Bates-Jensen Wound Assessment Tool [BWAT]
    • NPUAP’s Pressure Ulcer Scale for Healingtool (PUSH)
slide30
Reduction in ulcer size over 1-2 week period predict healing outcome

Should improvement within 2-4 weeks

If no evidence of ulcer improvement 

Consider changes in management strategy

Improvement for stage III and IV slower than II

Stage II: 75% healing in 60 days

Stage III or IV: 17% healing in 60 days

management
Management

Local treatment

Surgery

Drugs

Nutrition

local treatment
Local treatment

Debridement of necrotic tissue

Adequate wound cleaning

Application of appropriate topical therapy

debridement
Debridement
  • Wound debridement:
    • Reduce necrotic tissue burden
    • Decrease infection risk
    • Promote granulation tissue formation
    • NOT indicatedfor dry eschar on the heel or when the pressure ulcer on an ischemic limb
    • 5 methods of debridement: clinician preference, avalibility
  • Surgical or sharp debridement for extensive necrosis or when obtaining a clean wound bed quickly is important
  • More conservative methods (autolytic and enzymatic) for those in long-term care or home care environments
  • Adequate wound debridement is essential to wound bed preparation and healing.
surgical debridement
Surgical debridement
  • use of a scalpel, scissors, or other sharp instruments to remove nonviable tissue.
  • most rapid form of debridement
  • indicated over other methods
    • for removing thick, adherent, and/or large amounts of nonviable tissue
    • when advancing cellulitis or signs of sepsis
mechanical debridement
Mechanical debridement
  • Use of wet-to-dry dressings, whirlpool, lavage, or wound irrigation.
  • Wet-to-dry gauze dressings continue to be used for debridement
  • Disadvantages:
    • increased time/labor for application/removal of the dressings,
    • removing viable tissue as well as nonviable tissue
    • pain
  • Used cautiously, can traumatize new granulation tissue and epithelial tissue
  • Adequate analgesia should be administered
enzymatic debridement
Enzymatic debridement

Applying a concentrated, commercially preparedenzyme to the surface of the necrotic tissue

aggressively degrade necrosis by digesting devitalized tissue

3 commercially enzymes in USA: collagenase, papain-urea, and papain-urea with chorophyllin

Some of the effects attributed to autolysis

Debridement faster than with autolysis

More conservative than sharp debridement

autolytic debridement
Autolytic debridement
  • Using the body’s own mechanisms to remove nonviable tissue.
  • Maintaining a moist wound environment allows collection of fluid at the wound site, which allows enzymes within the wound fluid to digest necrotic tissue.
  • Adequate wound cleansing to wash out the partially degraded nonviable tissue.
  • More effective than wet-to-dry gauze dressings,
    • selectively removes only necrotic tissue
    • protects healthy tissues
  • May be slower to achieve a clean ulcer bed than other methods.
biosurgery
Biosurgery

The application of maggots (disinfected fly larvae, Phaenicia sericata) to the wound

Typically at a density of 5 to 8 per cm2

May not be acceptable to all patients

May not be available in all areas

adequate wound cleaning
Adequate wound cleaning

General rule

Pressure ulcer cleaning at changing dressing

If an ulcer contains necrotic debris or is infected, then antimicrobial activity is more important.

For wounds with large amounts of debris, more vigorous mechanical force and stronger solutions may be used

For clean wounds, less force and physiologic solutions such as normal saline should be used.

slide40
Should not use on clean pressure ulcers :

Povidone-iodine

Iodophor (易多碘)

Sodium hypochlorite (次氯酸鈉)

Hydrogen peroxide (H2O2)

Acetic acid

Toxic to fibroblast and impair wound healing

topical therapy
Topical therapy

Using moist woundhealing dressings

Moist wound healing allows wounds to re-epithelialize up to 40% faster than wounds left open to air

These dressings are changed every 3 to 5 days, which allows wound fluid to gather underneath the dressing, facilitating epithelial migration

surgery
Surgery

Primary closure

A variety of approaches to skin graft and myocutaneous flap

Removal of underlying bony prominence

Large infected pressure ulcers: more aggressive procedures ex amputation sometimes required

drugs antibiotic
Drugs - Antibiotic
  • Antibiotics
    • Antibiotics may be systemic or local
  • Systemic antibiotics:
    • S/S of systemic infection, sepsis or cellulitis with fever and elevated WBC
    • Osteomyelitis
    • Prevention of bacterial endocarditis in patients with valvular heart disease
    • Who require debridement of pressure ulcer
  • Broad-spectrum coverage
    • GNB, GPC, anaerobes
drugs antibiotic1
Drugs - Antibiotic

Appropriate choices for antibiotic therapy

Unasyn

Imipenem

Meropenem

Timentin

Tazocin

Combination of clindamycin or metronidazole with ciprofloxacin, levofloxacin, or aminoglycosides

Vancomycin for MRSA

drugs antibiotic2
Drugs - Antibiotic

The most effective strategy for preventing infection and dealing with existing infection is adequate debridement of necrotic tissue

In patients with S/S of systemic infection and sepsis, the appropriate debridement method is surgical debridement.

drugs antibiotic3
Drugs - Antibiotic

Topical antibiotics (silver sulfadiazine):

For stage III or IV ulcers with evidence of local infection

For clean pressure ulcer not healing after 2-4 weeks of optimal management

Prolonged silver release topical dressings: effective in MRSA colonization

drugs pain
Drugs - Pain

Limited evidence to guide clinician

Pressure ulcer alone: may not require routine pain medication

Medication prior to procedures is essential

Opioids and/or NSAIDs 30 minutes prior to the procedure

Topical anesthetics or topical opioids

nutrition
Nutrition

Difficult to define a causal relationship between malnutrition and pressure ulcer development

Some evidence: nutritional support to persons at risk for pressure ulcers with relative reduction in pressure ulcer incidence of 25%

Some evidence: high-protein nutritional supplements (24-25% protein) improves pressure ulcer healing

30 to 35 kcal/kg/d

1.25 to 1.5 g/kg/d of protein

nutrition1
Nutrition

Nutritional supplementation by tube-feeding to persons with pressure ulcers: notpositive results

No evidence exists for use of supplemental vitamins or minerals (e.g., vitamin A, E, C, zinc) in persons with pressure ulcers, except for deficiency

Persons with pressure ulcer or at risk + malnutrition: Nutritional assessment, nutrition support as indicated

Glutamine, Arginine, HMB

prevention
Prevention

Scheduled turning and repositioning programs

Pressure reduce/relieve support surfaces

General skin care

Nutritional support

scheduled turning and repositioning programs
Scheduled turning and repositioning programs

Patient at risk, unable to move independently

Time interval: every 2 Hrs

Avoid pressure on bony prominence, esp malleolus, trochanter: 30-degree side-lying instead of 90-degree side lying

Maintain head of bed at lowest degree of elevation: decrease sacral area exposure to shearing force

Techniques: Turning sheets, draw sheets, pillows

pressure reduce relieve support surfaces
Pressure reduce/relieve support surfaces

Static

Foam, gel, static air, water, combination

Less expensive

Dynamic

Alternating air(間歇式氣墊), low-air-loss(低壓氣浮床墊), or air-fluidized(矽砂床)

Use if the status surface is compressed to < 1 inch or high-risk patient has reactive hyperemia on a bony prominence despite use of static support

Adverse effects: dehydration, sensory deprivation, loss of muscle strength, difficulty with mobilization

pressure reduce relieve support surfaces1
Pressure reduce/relieve support surfaces

May reduce frequency of repositioning required in some paitents

Relative reduction in incidence of 60%

general skin care
General skin care

Skin inspection

Daily, esp attention to bony prominence

Reddened areas should notbe massaged

Incontinence assessment and management

Skin hygiene intervention

reference
Reference

Hazzard’s Geriatric Medicine and Gerontology, 6th ed. New York: Mc Graw Hill, 2009:703-715

Textbook of Geriatric Medicine International, Souel: Argos, 2010:411-418

NPUAP (National Pressure Ulcer Advisory Panel): http://www.npuap.org/