1 / 110

+ + +

+ + +. No Disclosures. Center For Colon & Rectal Surgery. Center For Colon & Rectal Surgery. What do these have in common?. PRESSURE ULCERS. Sam Atallah, MD General Surgery Colon & Rectal Surgery August 11, 2009. + + +. General Considerations. Basic Principles in Wound Healing

wylie
Download Presentation

+ + +

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. + + +

  2. No Disclosures

  3. Center For Colon & Rectal Surgery

  4. Center For Colon & Rectal Surgery

  5. What do these have in common?

  6. PRESSURE ULCERS Sam Atallah, MD General Surgery Colon & Rectal Surgery August 11, 2009

  7. + + +

  8. General Considerations • Basic Principles in Wound Healing • Importance of Oxygen • Effect of Edema • Role of Tissue Necrosis and Exudate • Understanding the Chronic Wound

  9. Basic Principles in Wound Healing • Epithelialization is more rapid under moist conditions compared to dry conditions • Winter and Scales (Nature, 1963) • Without dressings a superficial wound with minimal devitalized tissue will scab as blood and serum coagulates • This forms a protective moisture barrier • Epithelialization occurs with controlled clot proteolysis and migration of the epithelium under the clot

  10. Basic Principles in Wound Healing • When a wound is kept moist with an occlusive dressing, the exudate does not become infected and epithelial migration is optimized • Example: skin graft donor sites will epithelialize faster under an occlusive dressing • Pain is also reduced under an occlusive dressing

  11. Basic Principles in Wound Healing • “Moist Healing” can be achieved by • occlusive dressings • occlusive ointments or creams • continually moistened dressings

  12. Basic Principles in Wound Healing • The traditional wet-to-dry dressing actually produces desiccation and necrosis on the surface layer of the wound when it’s allowed to completely dry • Wet-to-Dry dressings are effective for debridement of wound exudate, but a moist healing environment combined with water irrigation is probably more effective

  13. Importance of Oxygen • Oxygen is key for normal metabolic cellular function • Wounds are actively proliferating and have a higher metabolic demand, so oxygen is even more important

  14. Importance of Oxygen • PMNs require ambient pO2 level of 25 mmHg • At this level, superoxide radicals are formed • Important bacteriocidal properties • Enzymes that make superoxide prefer pO2 of 50mmHg • Collagen synthesis requires a high oxygen tension

  15. Importance of Oxygen • Fresh wounds are hypoxic with low oxygen tension • Fresh wounds are initially avascular and therefore hypoxic • Measurements of pO2 at the center of a fresh wound approach 0 mmHg • pO2 rises quickly with angiogenesis

  16. Importance of Oxygen • In general, wound pO2 is lower than surrounding tissues • Atherosclerosis and small vessel disease can cause impaired oxygen delivery • Local scar and fibrosis can reduce normal pO2 (40 mmHg) to 25 mmHg or lower

  17. Importance of Oxygen • Other systemic factors may contribute to wound hypoxia: • Hypovolemia • Anemia (DD O2) • Alkalosis, other causes of LEFT shift in Hb-O2 curve • Systemic vasoconstriction, sepsis, excessive catacholamines • Smoking related arteriopathy • Diabetes

  18. Importance of Oxygen • Suboptimal tissue oxygen levels correlate with post-op wound infections • Increasing FiO2 to 80% during colonic resection decreases the rate of post-op wound infections • Oxygen delivery to tissue is the primary determinant of healing • Jonsson, Jensen, Goodson, et al. Ann Surg 1991 • Vienna Sudy New England Journal 2000 • Cornell JAMA 2004

  19. Importance of Oxygen • Hyperbaric oxygen therapy does result in high oxygen levels in most wounds • Treatments 1.5 hrs; 2-2.5 Atm; 100% O2 • What happens when between treatments? • No conclusisve data to show efficacy • Lack of prospective, randomized trials • No standards for indication, length, and duration of treatment • Used especially for diabetic foot ulcers and irradiated wounds • Consider as adjunct for obligate anaerobic necrotizing soft tissue infection

  20. Effect of Edema • In tissue, cells receive oxygen by diffusion from nearby capillaries • Inflammation and venous insufficiency lead to edema, as does poor nutritional status (low serum albumin) • This increases diffusion distance and results in lower tissue pO2 • Edema control - even when tissue isn’t noticeably swollen can be very beneficial • Extremity elevation • Compression stocking (esp. venous stasis ulcers) • SCDs • Elastic wraps (athletics)

  21. Role of Tissue Necrosis and Exudate • Open wounds contain devitalized tissue • Devitalized tissue is problematic because: • It becomes super-infected with microbes • It leads to poor tissue perfusion • Exudate is made up of serum proteins and dead inflammatory cells • Exudate increases devitalized tissue mass, and therefore must be cleared

  22. Role of Tissue Necrosis and Exudate • Devitalized tissue must be surgically excised, especially dermis • Why dermis? • If necrotic dermis is left in place, the underlying subcutanous adipose tissue which is LESS vascular than overlying dermis will become infected • For small areas of devitalized tissue, simple washings, whirlpool, water irrigation are sufficient but GOLD STANDARD is surgical ‘sharp’ debridement

  23. Understanding the Chronic Wound • What is a ‘chronic’ wound? • Fails to heal after 3 months • Examples: • Pressure Sore • Leg Ulcer • Foot Ulcer

  24. Understanding the Chronic Wound • Are CHRONIC wounds intrinsically different from ACUTE wounds? • Bottom line: Chronic wounds resist healing because they lack key factors (as mentioned, oxygen tension, etc) • The goal is to correct as best as possible those systemic factors

  25. ++++

  26. Treatment & ManagementOf Pressure Sores

  27. Pressure Sores - Background • Common problem • 148 Hospitals • Incidence of clinically identified pressure sores is 9.2% (Meehan) • Skilled care / RN homes range (2.4% - 23%) • Expensive problem • Exceeds $ 1.3 Billion (USA)

  28. Pressure Ulcers Terminology 101

  29. Terminology • Decubitus Ulcer • Bed Sore • Pressure Sore (prefered) • Pressure Ulcer (acceptable)

  30. Pressure Sores • Not always acquired in bedridden patients • Although: “The Bed Is The Enemy” • Not always acquired while in lying in decubitus (supine) position • All pressure sores involve two things: • Prolonged pressure • Over a bony prominence • Overlying the ischium • Overlying the sacrum • Overying the trochanter • Less common: Heel, Knee, Ankle

  31. Atypical Locations • Only 1.6 % of pressure ulcers are outside of the pelvic region or lower extremities

  32. What factors determine the ability of tissue to withstand pressure? • Duration of the pressure • Amount of pressure • Related shear forces

  33. What insult is caused by prolonged pressure? • Most important: Occludes the microcirculation • This happens when tissue pressure exceeds capillary filling pressure (25mmHg) • Doesn’t take much . . . Result is ischemia • Pressure over the sacrum can reach 80mmHg in a recumbent patient • Without frequent changes in position, tissue necrosis can result in hours

  34. Dermal and Soft Tissue Properties • Skin is more resistant to pressure than the underlying subcutaneous fat and muscle • Often, this leads to the finding of a small area of skin necrosis overlying a broad area of soft tissue and fat necrosis • Like an ICEBERG

  35. Stages of Pressure Ulcers

  36. Different Standards Three classifications that are commonly used: 1.NPUAP Staging (National Pressure Ulcer Advisory Panel, 1989) 2.IAET (International Association Enterostomal Therapy, 1988) 3.WOCN Staging (Wound Ostomy and Continence Nurses Society, 1992)

  37. Stage I (NPUAP) Pressure Ulcer • Erythematous and Edematous skin • Blue or purple (like a bruise) in dark pigmented pts • Skin is intact • Often tender to touch • Skin temperature variance (warm or cool) • Changes is skin consistency (firm or boggy) • Patient may complain of itching, burning, or pain

  38. Stage I (NPUAP) Pressure Ulcer

  39. Stage II (NPUAP) Pressure Ulcer • Partial Skin loss • Varying depths into dermis • Visible, yellow debris • Shallow crater • Occasional blistering

  40. Stage II (NPUAP) Pressure Ulcer

  41. Stage III (NPUAP) Pressure Ulcer • Full-thickness skin loss • Subcutaneous soft tissue exposure • Often, associated soft tissue necrosis • Stage III does not extend beyond the underlying fascia • Undermining of adjacent tissue may be seen

  42. Stage III (NPUAP) Pressure Ulcer

  43. Stage IV (NPUAP) Pressure Ulcer • Full-thickness skin loss • Exposed subcutaneous tissue • Usually, the bony prominence is exposed • The bony cortex is typically involved • Extensive necrosis typical • Damage to deep tissues (muscle, tendon) • Undermining, sinus tracts can be seen

  44. Stage IV (NPUAP) Pressure Ulcer

  45. VAC Therapy

  46. Efficacy of VAC Therapy • Pre-treatment of pressure ulcers using subatmospheric pressure dressing enhances plastic surgical coverage (Raymond Horch, et al. European Pressure Ulcer Advisory Panel) • 2004 study, n = 89 pts • 6 weeks V.A.C. followed by fascia-cutaneous/myocutaneous flap closure • 93% of stage III and IV ulcers healed completely • 7.6% of V.A.C. treated stage III & IV sores completely healed vs. historic control of 3.5%

More Related