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.

1. 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.

2. 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

3. 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

4. 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%

5. 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%)

6. Morbidities associated with pressure ulcers Pain Disfigurement Septicemia Prolonged hospitalization Increased death rates quality issues

7. 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)

8. 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

9. 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

10. 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

11. 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

12. Pathophysiology Pressure ulcers are the result of mechanical injury to the skin and underlying tissues. 4 factors Pressure Shearing force Friction Moisture

13. Pathophysiology

14. 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

15. 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

16. 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

17. 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

18. Friction and Moisture Friction Cause intraepidermal blisters Superficial erosions Moisture Directly lead to maceration and epidermal injury Impact on friction forces

19. Assessment Risk assessment Assessment of pressure ulcer stage Assessment of pressure ulcer healing

20. 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

21. 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

22. 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

23. 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

24. 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。

25. 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。

26. 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)

27. 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

28. 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

29. 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)

30. 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

31. Management Local treatment Surgery Drugs Nutrition

32. Local treatment Debridement of necrotic tissue Adequate wound cleaning Application of appropriate topical therapy

33. 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.

34. 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

35. 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

36. 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

37. 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.

38. 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

39. 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.

40. 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

41. 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

42. 敷料種類

43. 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

44. 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

45. 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

46. 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.

47. 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

48. 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

49. 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

50. 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