Managing pressure sores

Management of pressure ulcers accounts for a significant proportion of healthcare resources. Pressure ulcers (or sores) are caused by pressure-induced necrosis of soft tissue and as such should be entirely preventable. Although pressure can be considered as the initiating insult, multiple factors also contribute to progression and development. Prevention and treatment of pressure ulcers requires a multidisciplinary approach. Recognition of at-risk patients and the introduction of preventative measures is the mainstay of prevention. Multiple adjuncts to pressure ulcer resolution such as pressure relief systems, nutritional supplementation, pharmaceutical debridement, antimicrobials, negative wound pressure therapy and surgery can be employed. Category I and II ulcers are treated conservatively with dressings and the removal of precipitating factors. Although the majority of pressure ulcers are managed by nursing staff without any medical intervention, deeper lesions with significant tissue necrosis and secondary infection may require surgical debridement and possibly reconstructive closure. The development of a pressure ulcer is often a reflection of significant comorbidity and treatment should be applied in the context of the patient's overall likely clinical outcome and prognosis.     

Managing pressure sores

Pressure ulcers are caused by pressure-induced necrosis of soft tissue and as such should be entirely preventable. However, management of pressure ulcers accounts for a significant utilization of healthcare resources. Although pressure can be considered as the initiating insult, multiple factors also contribute to progression and development. Therefore, treatment of pressure ulcers requires a multidisciplinary approach. Recognition of at-risk patients and the introduction of preventative measures is the mainstay of treatment. Multiple adjuncts to pressure ulcer resolution such as pressure relief systems, nutritional supplementation, pharmaceutical debridement, antimicrobials, negative wound pressure therapy, and surgery can be employed. Grade I and II ulcers are treated conservatively with dressings and the removal of precipitating factors. Deeper lesions with significant tissue necrosis and secondary infection may require surgical debridement and reconstructive closure. The development of a pressure ulcer is often a reflection of significant co-morbidity and treatment should be applied in the context of the overall likely clinical outcome and prognosis.     

Clinical features and management of pressure ulcers for the general surgeon

Although widely considered to be preventable, pressure ulcers (PU) are common and cause a significant burden to the individual, their carers and healthcare services. International collaborative panels publish consensus documents and guidelines aiming to standardize PU classification, assessment and management. There is a huge emphasis on prevention, which requires awareness and education for clinicians, patients and carers. Surgeons may be referred patients with PU for advice on surgical options or management of infected wounds. Surgical patients may develop PU after prolonged surgical procedures, during periods of critical illness or in association with their surgical condition. Additionally, as some PU become chronic and non-healing, individuals with PU may be referred for assessment of other medical issues. An awareness and understanding of PU aetiology, management strategies and complications are therefore important for the surgical trainee.     

Surgical treatment and strategy in patients with multiple pressure sores

Pressure sores remain a common health problem, particularly among the physically limited or bedridden elderly, and can cause significant morbidity and mortality. This study aimed to present our surgical treatment and strategy for patients with multiple pressure sores. Between January 2010 and December 2016, 18 patients were enrolled. After adequate debridement, pressure sores were managed based on our treatment protocol. Patients'' age, aetiology, defect size and location, flap reconstruction, outcome, and follow‐up period were reviewed. A total of 10 men and 8 women (average age, 82.3 years) with a mean follow‐up period of 28.3 months (6‐72 months) were included. The mean defect area was 63.7 cm². The most common aetiology of the bedridden state was cerebrovascular accident (38.89%), and the most frequent sores were trochanteric pressure sores (53.57%). The average operative time and blood loss were 105.5 minutes and 100.8 mL, respectively. No haemodynamic variation or blood transfusion was noted during the surgery. The complication rate for each sore was 10.7%, including late recurrence. In conclusion, treating pressure ulcers requires careful patient education, intensive multidisciplinary optimisation, and meticulous wound care, and our treatment protocol ensures a shorter surgery time, less bleeding, and low complication rate.     

Ideal treatment modality for trochanteric pressure sores

In this study, a retrospective comparison between musculocutaneous and fasciocutaneous flaps in the treatment of trochanteric pressure sores was performed. From 1988 to 1996, 62 patients with 82 trochanteric pressure sores were treated surgically. The median age of the patients was 33.2 years with 50 males and 12 females, 20 patients had bilateral trochanteric pressure sores; 25 pressure sores were treated by musculocutaneous flaps and 57 with fasciocutaneous flaps. The comparative advantage of musculocutaneous and fasciocutaneous flaps in the surgical treatment of pressure sores is controversial. This study was performed to determine the ideal treatment modality. It showed that there was no significant difference in the recurrence rates. Received: 14 March 1997 / Accepted: 21 August 1997     

负压封闭引流技术治疗压疮的实验研究

目的通过负压封闭引流技术治疗压疮的动物实验研究,探索治疗压疮的有效方法。方法将雄性新西兰兔建立压疮模型后随机分为4组(每组12只):对照组创面涂抹蛋清,单纯负压组单纯使用负压封闭材料覆盖,钻孔负压组使用负压封闭材料覆盖结合骨组织钻孔,生长因子组使用负压封闭材料覆盖结合成纤维细胞生长因子,每周更换负压封闭材料进行创面观察(肉芽组织情况,创面表面积,切取创面组织行切片HE染色)。结果除对照组创面于5周愈合外,其余3组均于4周愈合。第1周创面表面积钻孔负压组及单纯负压组大于对照组(P0.05);单纯负压组、钻孔负压组、生长因子组于第1、2、3周HE染色纤维细胞密度均大于对照组(P0.05)。结论负压封闭引流技术治愈压疮切实有效,早期结合使用促软组织生长方法可加强疗效。     

Ischial pressure sores treated with a sensate gracilis myocutaneous flap

There are problems in finding a definitive treatment of ischial pressure sores because recurrence is frequently observed. The aim of surgical procedures is to cover the ischial region with stable and durable tissue, which has a good neurovascular supply. If the patient with ischial pressure sores has sensation above L3 level, the sensate gracilis musculocutaneous flap can be used to treat the defect after resection of the decubitis. This treatment was performed in 12 paraplegic patients in whom sensation was absent below the L3 level. The median age of the patients was 32.5 years, with ten males and two females. Four patients had recurrent pressure sores. The average time of follow-up was 8 months. Sensation was assessed with moving finger tip pressure, warm and cold cylinders, two point discrimination and dermal cortical somatosensory-evoked potential tests. Sensation was present in the transferred flap. Although the gracilis myocutaneous flap can also be used as a nonsensory flap for the reconstruction of ischial pressure sores in paraplegic patients under L3 level, the sensate gracilis myocutaneous flap should be chosen primarily when there is sensation over the gracilis region. Received: 16 March 1999 / Accepted: 14 September 1999     

负压封闭引流结合臀大肌肌皮瓣在骶尾部褥疮修复中的应用

[目的]探讨负压封闭引流(VSD)结合臀大肌肌皮瓣修复骶尾部褥疮的临床效果.[方法]选择2005年2月～2009年2月收治的骶尾部褥疮患者31例,男17例,女14例;年龄30～ 75岁,病程0.2 ～20年.创面面积:5cm×6.5cm～8cm×12.5cm.随机分为两组:治疗组16例,创面先经负压封闭引流处理,设计以臀上动脉浅支为血管蒂的臀大肌上部肌皮瓣,修复骶尾部褥疮.对照组15例,常规换药处理后臀大肌上部肌皮瓣修复.[结果] 29例患者皮瓣一期存活,试验组和对照组各有1例皮瓣远端部分坏死,经换药后愈合.治疗过程中无大出血、血管神经损伤、感染等并发症.所有患者均获随访,随访时间12 ～18个月,肌皮瓣质地良好,褥疮无复发,功能满意.试验组在换药次数、住院时间及抗生素使用等方面优于对照组,差异有统计学意义(P＜0.01).[结论]应用负压封闭引流结合臀大肌肌皮瓣修复骶尾部褥疮,能够明显缩短病程,并发症少,成功率高,是治疗骶尾部褥疮的理想方法之一.     

The accordion gracilis muscle flap: a new design for coverage of recurrent and complicated ischeal pressure sores

Management of patients with large or recurrent pressure ulcerations can be complicated by the lack of available local flap, whether already used or because adjacent lesions make such flap insufficient for complete coverage. In this article, the gracilis muscle was modified to cover large defects without help from its cutaneous territory. Twelve ischeal pressure sores were treated between August 2007 and 2009 with the modified gracilis muscle flap in a single-staged procedure. Five ulcers were recurrent and seven patients have associated pressure ulcers. All reconstructions were successful. Mean patient age was 35 years and nearly all patients had multiple significant comorbidities, including associated ulcers, diabetes and urethrocutaneous fistula. All flaps and donor sites healed uneventfully. There was one complication presented as cellulites at the donor site. Follow-up in some cases extend up to 1·5 years. No recurrence was observed. The accordion gracilis muscle flap is a handy, safe and fast flap for reconstruction of recurrent, difficult ischeal pressure sores.     

The inferiorly based rectus abdominis myocutaneous flap for recurrent pelvic pressure sores in neurologically impaired patients

Summary The inferiorly based rectus abdominis myocutaneous flap, developed by Taylor, is a reliable flap which when raised spares the anterior sheath of the muscle below the arcuate line. The muscle can fill an infected, hypovascular wound and the extensive skin paddle can cover a large cutaneous loss of substance, so the flap is perfectly suited to coverage of recurrent pressure sores in paraplegic patients. We used 11 flaps in 10 paraplegic patients for recurrent pelvic pressure sores which were ischial in six cases, trochanteric in four and sacral in one. We describe the operative technique and stress the importance of using an extraperitoneal, intrapelvic and transiliac approach. Healing was obtained in all cases without functional deficit of the abdominal wall (no abdominal herniation, one contour deformity). This flap offers two further options for treatment of recurrent pelvic pressure sores whatever their location and its indications are more and more frequent in an aging population of paraplegic patients.     

Risk factors for pressure sores in the critically ill

Pressure sore development in the critically ill is a well-recognised problem and several risk factors have been put forward as being relevant; however, none has been proved valid in this population. This study examines the effects of specific risk factors for the development of pressure sores in the critically ill. Data on 22 specific risk factors were recorded every 8 h. Of 286 patients who were identified as having a minimum set of three predetermined risk factors, 77 developed pressure sores. Using univariate regression analysis, 18 of the 22 specific factors were identified as being significant (p < 0.05) in the development of pressure sores. Multivariate analysis identified five of these 18 specific risk factors as being independently significant (p < 0.05) in pressure sore development. These five factors were norepinephrine infusion, APACHE II score, faecal incontinence, anaemia and length of stay.     

The long-term management of sacral,ischial and trochanteric pressure sores by Myocutaneous Island flaps and their postoperative course

Summary Thirty-three patients, mostly paraplegics, were treated for chronic pressure sores Campbell stages IV–VI overlying the sacrum, the ischial tuberosity and the femoral tuberosity. A stable, multi-layered cover of the defect, following excision of the decubiti, could be achieved in one stage using single myocutaneous gluteus maximus and biceps femoris island flaps or, when indicated, a combination of both. The postoperative complication rate was 7/65 (65 myocutaneous flaps were used in 33 patients) or 10.8%. Except for one recurrence due to a traumatic hematoma causing subtotal, external compression of the axial vascular pedicle and consequent partial necrosis of the myocutaneous island flap, all other flaps provided adequate closure and padding. They provided durable cover over a mean follow-up period of 25 months. These results are compared with the relevant literature.     

游离植皮结合负压封闭引流技术治疗难治性褥疮创面

目的：探讨难治性褥疮创面植皮后使用负压封闭引流（vacuum sealing drainage,VSD）技术的临床效果。方法：对16例难治性褥疮患者有效清创,待缺损区创面新鲜时,取刃厚皮片或薄中厚皮片,大块邮票状植皮后,VSD敷料结合半透膜覆盖。结果：16例患者植皮完全成活,2例患者去除VSD敷料后,边缘少许坏死,积极换药后成活,皮片功能均恢复正常。结论：该手术方法操作简单,术后护理方便,是对部分褥疮患者一种较理想的植皮方法。     

Managing the open wound: indications for topical negative pressure therapy

Surgeons frequently encounter open wounds. These include wounds which have failed to close by primary means, wounds which are left open at the outset and wounds which fail to heal by secondary intention in a timely manner. Wound healing is a complex process involving tissue repair and remodelling at the same time as removal of necrotic tissue and foreign material. Topical negative pressure (TNP) is a wound management technique which applies subatmospheric pressure to a healing wound in an attempt to facilitate healing. The potential mechanisms of action of TNP are poorly understood and may involve mechanical and biochemical effects. TNP has been suggested to be of value in a variety of settings, ranging from management of acute wounds to ischaemic and diabetic ulcers. There has been inadequate scientific evaluation of TNP, which has rarely been subjected to rigorous clinical trials or adequate effective economic evaluation. Although in general TNP does appear to be largely safe and acceptable to patients, the risk of fistulation associated with its use in the open abdomen remains to be determined and is currently being evaluated by a national audit.     

Closed incision negative pressure therapy following abdominoplasty after breast reconstruction with deep inferior epigastric perforator flaps

Autologous breast reconstructions using deep inferior epigastric perforator (DIEP) flaps create a large incision, presenting an opportunity for surgical site complications. In this pilot study, we aimed to examine outcomes in DIEP donor site incisions managed with standard dressings (control; n = 5) or closed incision negative pressure therapy (ciNPT; n = 5). We observed no significant differences between group age, body mass index, and past medical history. Both treatment groups had a similar duration of hospital stay, the number of blood transfusions, and pain scores on postoperative day 2 (P > .05). There was a trend of higher drainage (P = .251) and shorter time to incision healing (P = .067) in the ciNPT group than the control though the difference was not statistically significant. We did observe a significant improvement in scar pigmentation, vascularity, and pliability at 3, 6, and 12 months post‐surgery in the ciNPT group compared with control (P < .05). No surgical site complications were reported in the ciNPT group within the follow‐up period. In the control group, one patient developed wound edge fat necrosis requiring reoperation. In conclusion, we report that ciNPT is a useful incision management system for DIEP flap donor site incisions and it facilitated improved scar quality over standard dressings in this small pilot study. Further clinical studies are required to assess the full advantages provided by ciNPT.     

Allogenic platelet gel in the treatment of pressure sores: a pilot study

Although platelet gel is considered one of the most popular tools in the treatment of chronic ulcers, current consensus on its use is not unanimous. A prospective randomised trial was carried out at the Plastic Surgery Unit of the ‘Salvatore Maugeri’ Foundation Hospital of Pavia (Italy). The study involved 13 patients affected by spinal cord injury with 16 pressure sores over a period of 20 months. The ulcer was considered the experimental unit of the study irrespective of the number of ulcers per patient. Each consecutive ulcer was randomised to be treated either with allogenic platelet gel or with current best practice approach to chronic wounds dressing protocol. At the end of the treatment 15 ulcers out of 16 improved clinically. No statistically significant difference was demonstrated in volume reduction between the two groups, although a statistically significant difference could be demonstrated in the onset time of granulation tissue proliferation as in the wounds treated with platelet gel the healing process was triggered earlier. Our study suggests that platelet gel is mostly effective within the first 2 weeks of treatment while a prolonged treatment does not provide any significant advantage versus the current best practice approach to chronic wounds protocols.     

Surgical treatment of pressure sores

The purpose of this study was to identify the most common complications and the recurrence rate following surgical correction of pressure sores. A total of 415 decubitus ulcers in 301 patients treated surgically were analyzed. The patients’ ages ranged from 2 to 95 years (mean 40 years). Forty-one percent of the patients were paraplegics. The follow-up period was about 18 months. It was verified that patients with spinal cord injury, those with chronic disease, and those of advanced age are the groups at high risk of pressure sore development. The most common sites of ulcer development were the sacrum, trochanters, ischium, and around the ankle and heels. There was a high rate of recurrence but a low rate of complications. It was concluded that a successful outcome in pressure sore management depends on an aggressive operation to radically remove the affected tissues including bone prominences, and to secure cover, preferably with a reliable muscle flap whenever possible. Received: 29 July 1998 / Accepted: 20 January 1999     

压力传感器用于预防老年俯卧位手术患者压疮的效果

目的观察压力传感器在预防老年俯卧位手术患者术中面部压疮的应用效果,以降低术中体位性压疮的发生。方法将行全麻俯卧位脊柱后路手术的老年患者200例随机分为对照组和观察组,每组100例。两组按常规方法摆放手术体位,使用马鞍形硅胶头托固定头颈部,对照组巡回护士根据临床经验,每30分钟转换头部受压部位1次。观察组马鞍形硅胶头托内放置压力传感器,巡回护士根据计算机显示高数值部位,每30分钟转换头部受压部位。结果术后不同时间观察组面部皮肤受损程度显著低于对照组(均P0.01)。术后0.5h,观察组仅2例处于Ⅰ级皮肤损伤,而对照组仍有12例处于Ⅰ级皮肤损伤,1例处于Ⅱ级皮肤损伤,且术后12h有2例皮肤损伤由Ⅰ级进展到Ⅱ级。结论使用压力传感器可有效降低俯卧位手术老年患者面部皮肤压疮的发生,对于老年患者面部皮肤及器官的保护具有积极意义。     

Our experience with ischial pressure sores in a series of 34 patients

Ischial pressure sores cause important social and occupational problems for patients with sensorimotor handicaps. Repeated hospitalizations are detrimental to their working status and the requirement for daily local care can be a major burden. Preventative measures, including an adapted wheelchair, regular decompression, daily self-surveillance, and local care, can be effective, but when constituted, pressure sores in patients who wish to resume normal social and occupational activities require effective and long-lasting surgical repair. We report surgical management of ischial pressure sores in a series of 34 paraplegic or tetraplegic patients, comparing surgical parameters and outcome for the different coverage techniques used. Outcome after 10 years of regular follow-up would suggest that the Griffith fasciocutaneous flap combined with a muscle flap using the hamstring muscles provides the most favorable results. Received: 10 March 1999 / Accepted: 8 June 1999