Decubitus

Aetiology

Pressure sores (LDD), also called pressure ulcers, are areas of injury to the skin, underlying tissues or both of these structures, caused by prolonged pressure on the skin which causes a temporary interruption of blood supply to the skin . LDDs tend to occur in regions where bony prominences are found and therefore pressure on the skin can be more concentrated.

Traction also reduces cutaneous blood flow. For example, traction occurs when people are placed on an inclined plane (as if they are seated on an inclined bed) and their skin is stretched. The muscles and tissues under the surface layer of the skin are pushed down by gravity, but the surface skin layer remains in contact with the external surface (such as the sheets). When the skin is stretched, an effect very similar to that of pressure is obtained.

Friction (rubbing against clothing or bedding) can cause, or worsen, pressure sores. Repeated friction can remove the superficial skin layers. Such friction of the skin can occur, for example, if the body is repeatedly pulled to be accommodated on the bed.

Moisture can increase the friction of the skin and weaken or damage its protective outer layer, if the skin is exposed to moisture for a long period of time. For example, the skin may remain in contact with sweat, urine (due to urinary incontinence) or feces (due to faecal incontinence) for a prolonged period.

Staging

To identify treatment plans best suited to each possibilities, the LDDs are divided in four stages:

  • Stage I: redness of the skin that does not disappears at acupressure. The skin is red or pink but it is not open. The area can also be warmer, colder, firmer, softer or more painful than adjacent surfaces;
  • Stage II: a loss of skin tissue with or without real ulceration; subcutaneous tissue is not exposed. The ulcer is shallow with a pink to red base. Stage II also includes intact or partially broken blisters secondary to pressure.
  • Stage III: a loss of continuity to everything thickness, without affecting the underlying muscle and without bone exposure.
  • Stage IV: a loss of substance to everything thickness with exposure of the bone, tendon or underlying muscle.

Treatment

  1. 1. Pressure reduction

The reduction of tissue compression is achieved through correct patient positioning, protective devices, and the use of support surfaces. The frequent change of position (and the choice of the most suitable position) is of utmost importance. Protective padding such as cushions, foam wedges, and heels can be placed between the knees, ankles, and heels when patients are supine or on one side. In patients immobilized by fractures, fenestrations must be cut in the plaster casts in the points subjected to pressure. Patients who are able to sit in a chair should be provided with soft cushions.

2. Dressings

There are numerous types of dressings for the treatment of pressure sores. In all cases the main objectives treatments are:

– pressure relief;

– cleaning and bandaging the wound;

– pain management;

– infection control.

Sometimes it is necessary to seek help from surgery to promote deep cleansing of wounds.

To reduce pressure on the skin, patients should be carefully positioned and assistant should use devices of protection and prevention on the surfaces. In the early stages the injuries usually heals spontaneously when pressure is removed.

For healing, lesions must be cleaned and flushed with a saline solution or with disinfectants depending on the evaluation of the inflammatory state. After cleansing you can run the dressing. Dressings are used to protect the ulcer and promote healing. If the skin is torn, a doctor or nurse will assess the location and status of the plague to recommend right type of dressing. The amount of drainage that exudes from sores helps to establish the most suitable type of dressing.

A highly specialized type of dressing for deep wounds that generate large quantities of exudate is Topical Negative Pressure Wound Therapy (NPWT). Negative Pressure Therapy collects high volumes of exudate and therefore decreases the frequency of dressing changes and therefore exposure of the wound to the environment. Kinetic concepts such as suction that promotes tissue regeneration, microdeformation, increased perfusion and removal of infection and exudate may also intervene. Although there is no scientific evidence that indicates negative pressure dressing for the healing of pressure ulcers as “indispensable”, this therapy is used whenever it becomes available because it guarantees better wound cleaning and elimination of bad odor factors that contribute to greater patient comfort. In recent years, the healthcare costs of using the pumps for negative pressure bedsore therapy have increased by 600% in 6 years from 2001 to 2007.

Bibliography

Guidelines for Preventing and Treating Bedsores from the American College of Physcians (https://www.acponline.org/acp-newsroom/american-college-of-physicians-releases-new-guidelines-forpreventing-and-treating-bedsores)

Venous ulcers

Venous ulcers are wounds that appear between the ankle and the knee as a result of an insufficient blood supply to the lower limbs. They are quite common and generally affect the elderly, especially women and obese people. They are generally associated with a state of venous hypertension due to chronic venous insufficiency, or thrombosis of the saphenous vein with obstruction of the return of venous blood. They start as brownish discolorations that are followed by thinning of the skin and finally by a breakage of the skin forming ulcers of different depths. These ulcers can then also get infected.

They are classified in the following order depending on the underlying venous insufficiency:

  • C0: No visible or palpable signs of venous insufficiency
  • C1: Telangiectasia or venous reticulum
  • C2: Varicose veins
  • C3: Leg oedema
  • C4a: Skin alterations due to diseases of the veins (pigmentation, eczema)
  • C4b: Severe skin alterations due to diseases of the veins (dermatosclerosis, white atrophy)
  • C5: C4 + ulcers healed
  • C6: Skin changes with active ulcers

There are different types of therapy for venous ulcers and their underlying problems. First of all, it is important to identify the type of vascular disease that is causing it. If possible, once the disease is cured, a compression dressing is applied to the ulcers and changed until the wounds have healed. The compression phase of the dressing once was carried out with pinstriped boots (Unna boot); currently it is carried out with graduated elastic compression stockings. These ulcers easily reopen once the compression is removed. Sometimes these ulcers require grafting with medium-thick skin grafts. Healing with compression, in uncomplicated cases, takes about 40 days.

Compression therapy is considered the standard of treatment for venous ulcers.

Negative pressure therapy can be used for venous ulcers, although its superiority over other types of conventional therapies, with dressings and compression, has not been fully demonstrated. There is one particular study that shows that cutaneous healing with negative pressure therapy takes less time than with compression dressings.

In cases in which it is necessary to cleanse the ulcer, such as in preparation for a skin graft, negative pressure therapy is definitely more useful than the compression dressing.

In general, negative pressure therapy requires less frequent medications, is often self-managed by the patient or caregivers and is recently preferred by doctors and patients for its provision of greater patient comfort.

Surgical wounds healing by secondary intention

After surgery, wound margins are usually approximated by suturing, metal clips, glue or adhesive patches. These processes hold wound margins closed for a few days. This kind of healing is called “healing by first intention.” However, not all surgical incision are closed using these methods: if there is a risk of infection or there has been a significant loss of tissue so that the margins cannot be joined, the wounds are left open in order to allow them to heal bottom-up. This kind of healing is called “healing by second intention.” This process takes much longer than healing by first intention because the tissues that are missing or that are non-viable need to be replaced by viable cells. The open area is more extended and the consequent inflammatory reaction can become chronic. The healing may involve the formation of an eschar or scab composed of dry plasma and dead cells, and the cells of the surrounding vital tissues (fibroblasts and vascular tokens) migrate towards the center of the wound and form “granulation tissue” that is fragile and bleeds easily. Only in the last phase of healing does “re-epithelisation “occur, which is the growth of the outermost skin layer that sometimes partially retracts the wound.

For example, wounds resulting from the removal of pilonidal and fistulas, burns and other events that cause a loss of substance (such as after trauma), in which grafts and flaps are not indicated, are healed by second intention. Treating these open surgical wounds are challenging because they are large, deep, carry a high risk of infection and can produce a lot of fluid (called exudate), which is difficult to manage. The options available, in addition to absorbent dressings such as those with alginates, include the use of negative pressure therapy, which has become the most widely used form of advanced therapy for various types of wounds. The negative pressure therapy “sucks” the liquid that originates in the wound and collects it in a binder called a “canister.” This action keeps the wound dry and reduces the bacterial count. Some studies indicate that negative pressure therapy can reduce healing time by one-half to one-third compared to traditional dressings.

Diabetic foot

The diabetic foot is an open wound or injury that occurs mostly on the sole of the foot in about 15% of diabetic patients. These lesions usually appear in long-term diabetics and are the expression of a dual neurological and arteriopathic type of pathology. Diabetic neuropathy prevents the patient from feeling microtraumas to the foot, while diabetic arteriopathy reduces blood flow below what is sufficient to maintain the right tropism of the extremities and therefore the healing of small wounds.

The injuries of the diabetic foot are generally classified as follows (Wagner classification):

  • Grade 0: No injury, the foot is not at risk
  • Grade 1: Superficial ulcer
  • Grade 2: Complicated ulcer
  • Grade 3: Deeply complicated ulcer
  • Grade 4: Local gangrene
  • Grade 5: Gangrene of the entire foot

Diabetic foot ulcers, once formed, usually cause pain and tingling, especially if they concern the outside of the foot.

Negative pressure therapy plays a role in treating the diabetic foot, but the regimen of use differs from that of treatment of wounds by second intention.
In particular, a higher frequency of dressing changes is recommended.

What is necessary for the treatment of diabetic wounds:

  1. A surgical toilet with excision of all infected or devitalised tissue. Therapy in depression should not be applied to infected or necrotic tissue.
  2. It is best to perform the first negative pressure dressing in the operating room with a skilled surgeon.
  3. Subsequent treatments should be done by a doctor or nurse who is an expert in negative pressure therapy.
  4. Diabetic ulcers sometimes do bleed. In this case, an accurate haemostasis should be performed, verified by physiological solution washing, with the application of negative pressure therapy postponed for 24 hours, setting the depression at half the norm value (about 75 mmHg) for the first few days. Oscillating depression may be useful.
  5. If pus is present (diabetic ulcers become infected very frequently), it is necessary to apply the therapy in depression after an accurate cleansing and change the dressing strictly every 48 hours.
  6. At each change of dressing, detect if there is a bad smell; in this case, carefully redo the curettage of the ulcer.
  7. Patient albumin should exceed 32 mg / dL and haemoglobin 10 g / dL.
  8. It is recommended to use the dressing in depression only until healthy granulation tissue is evident. Subsequently, it is advisable to intervene with the positioning of a partial thickness graft.
  9. It is usually sufficient to reduce the wound by 40-60% by changing the dressing from 10 to 16 times over a period of 2 to 3 weeks.

Diabetic foot

The diabetic foot is an open wound or injury that occurs mostly on the sole of the foot in about 15% of diabetic patients. These lesions usually appear in long-term diabetics and are the expression of a dual neurological and arteriopathic type of pathology. Diabetic neuropathy prevents the patient from feeling microtraumas to the foot, while diabetic arteriopathy reduces blood flow below what is sufficient to maintain the right tropism of the extremities and therefore the healing of small wounds.

The injuries of the diabetic foot are generally classified as follows (Wagner classification):

  • Grade 0: No injury, the foot is not at risk
  • Grade 1: Superficial ulcer
  • Grade 2: Complicated ulcer
  • Grade 3: Deeply complicated ulcer
  • Grade 4: Local gangrene
  • Grade 5: Gangrene of the entire foot

Diabetic foot ulcers, once formed, usually cause pain and tingling, especially if they concern the outside of the foot.

Negative pressure therapy plays a role in treating the diabetic foot, but the regimen of use differs from that of treatment of wounds by second intention.
In particular, a higher frequency of dressing changes is recommended.

What is necessary for the treatment of diabetic wounds:

  1. A surgical toilet with excision of all infected or devitalised tissue. Therapy in depression should not be applied to infected or necrotic tissue.
  2. It is best to perform the first negative pressure dressing in the operating room with a skilled surgeon.
  3. Subsequent treatments should be done by a doctor or nurse who is an expert in negative pressure therapy.
  4. Diabetic ulcers sometimes do bleed. In this case, an accurate haemostasis should be performed, verified by physiological solution washing, with the application of negative pressure therapy postponed for 24 hours, setting the depression at half the norm value (about 75 mmHg) for the first few days. Oscillating depression may be useful.
  5. If pus is present (diabetic ulcers become infected very frequently), it is necessary to apply the therapy in depression after an accurate cleansing and change the dressing strictly every 48 hours.
  6. At each change of dressing, detect if there is a bad smell; in this case, carefully redo the curettage of the ulcer.
  7. Patient albumin should exceed 32 mg / dL and haemoglobin 10 g / dL.
  8. It is recommended to use the dressing in depression only until healthy granulation tissue is evident. Subsequently, it is advisable to intervene with the positioning of a partial thickness graft.
  9. It is usually sufficient to reduce the wound by 40-60% by changing the dressing from 10 to 16 times over a period of 2 to 3 weeks.

Surgical wounds healing by secondary intention

After surgery, wound margins are usually approximated by suturing, metal clips, glue or adhesive patches. These processes hold wound margins closed for a few days. This kind of healing is called “healing by first intention.” However, not all surgical incision are closed using these methods: if there is a risk of infection or there has been a significant loss of tissue so that the margins cannot be joined, the wounds are left open in order to allow them to heal bottom-up. This kind of healing is called “healing by second intention.” This process takes much longer than healing by first intention because the tissues that are missing or that are non-viable need to be replaced by viable cells. The open area is more extended and the consequent inflammatory reaction can become chronic. The healing may involve the formation of an eschar or scab composed of dry plasma and dead cells, and the cells of the surrounding vital tissues (fibroblasts and vascular tokens) migrate towards the center of the wound and form “granulation tissue” that is fragile and bleeds easily. Only in the last phase of healing does “re-epithelisation “occur, which is the growth of the outermost skin layer that sometimes partially retracts the wound.

For example, wounds resulting from the removal of pilonidal and fistulas, burns and other events that cause a loss of substance (such as after trauma), in which grafts and flaps are not indicated, are healed by second intention. Treating these open surgical wounds are challenging because they are large, deep, carry a high risk of infection and can produce a lot of fluid (called exudate), which is difficult to manage. The options available, in addition to absorbent dressings such as those with alginates, include the use of negative pressure therapy, which has become the most widely used form of advanced therapy for various types of wounds. The negative pressure therapy “sucks” the liquid that originates in the wound and collects it in a binder called a “canister.” This action keeps the wound dry and reduces the bacterial count. Some studies indicate that negative pressure therapy can reduce healing time by one-half to one-third compared to traditional dressings.

Venous ulcers

Venous ulcers are wounds that appear between the ankle and the knee as a result of an insufficient blood supply to the lower limbs. They are quite common and generally affect the elderly, especially women and obese people. They are generally associated with a state of venous hypertension due to chronic venous insufficiency, or thrombosis of the saphenous vein with obstruction of the return of venous blood. They start as brownish discolorations that are followed by thinning of the skin and finally by a breakage of the skin forming ulcers of different depths. These ulcers can then also get infected.

They are classified in the following order depending on the underlying venous insufficiency:

  • C0: No visible or palpable signs of venous insufficiency
  • C1: Telangiectasia or venous reticulum
  • C2: Varicose veins
  • C3: Leg oedema
  • C4a: Skin alterations due to diseases of the veins (pigmentation, eczema)
  • C4b: Severe skin alterations due to diseases of the veins (dermatosclerosis, white atrophy)
  • C5: C4 + ulcers healed
  • C6: Skin changes with active ulcers

There are different types of therapy for venous ulcers and their underlying problems. First of all, it is important to identify the type of vascular disease that is causing it. If possible, once the disease is cured, a compression dressing is applied to the ulcers and changed until the wounds have healed. The compression phase of the dressing once was carried out with pinstriped boots (Unna boot); currently it is carried out with graduated elastic compression stockings. These ulcers easily reopen once the compression is removed. Sometimes these ulcers require grafting with medium-thick skin grafts. Healing with compression, in uncomplicated cases, takes about 40 days.

Compression therapy is considered the standard of treatment for venous ulcers.

Negative pressure therapy can be used for venous ulcers, although its superiority over other types of conventional therapies, with dressings and compression, has not been fully demonstrated. There is one particular study that shows that cutaneous healing with negative pressure therapy takes less time than with compression dressings.

In cases in which it is necessary to cleanse the ulcer, such as in preparation for a skin graft, negative pressure therapy is definitely more useful than the compression dressing.

In general, negative pressure therapy requires less frequent medications, is often self-managed by the patient or caregivers and is recently preferred by doctors and patients for its provision of greater patient comfort.

Decubitus

Decubitus, also known as bed sores or pressure ulcers, are areas of the skin, the underlying tissues, or both, that are injured. Decubitus ulcers can be painful, are prone to infection, smell bad and can affect patients’ quality of life.
People at risk of developing decubitis ulcers include: the elderly, those who are bedridden for long periods of time, people with spinal cord injuries and sometimes people who remain seated for long periods of time in a static position. The social cost of decubitus ulcers is very high, reaching a level of 4% of public spending in some countries.
A large study of hospitalised patients revealed a prevalence of decubitus of 10.5%, reaching a level of 26% for long-term patients. Decubitus ulcers should be prevented in the first place by frequently moving patients who cannot move independently. When decubitis ulcers occur, they must be treated quickly.
Decubitus ulcers are divided into different stages in order to better define the therapies to be applied.

  • Stage 1: Skin still intact with redness that does not turn white when pressed against a bone surface. The area is usually sore, solid, soft and warmer in temperature than adjacent areas.
  • Stage 2: Partial thickness. There is a shallow open injury and the bottom of the wound is pinkish, without secretions. It can also present as a blood blister. No bruising is apparent. This stage is not to be confused with skin tears, patch injuries, burns or incontinence dermatitis.
  • Stage 3: Full thickness. The subcutaneous fat can be seen, but bones cannot. Tendons and muscles are exposed. There might be secretions, but the depth of the wound can still be determined. There might be possible sub-processes and tunneling.
  • Stage 4: Full thickness with exposure of the bones, tendon and muscles. There might be secretions and eschars. There is often subduing and tunneling.

Over the years, many useful therapies have been used to address decubitus ulcers, such as dressings, creams and weight redistribution. Only more recently has negative pressure therapy been utilised. NPWT is implemented by first debriding and cleaning the wound, then placing a back sponge in the wound under gentle suction. The liquid produced by the wound is aspirated and collected in a container. Negative pressure therapy collects high volumes of exudate, thereby reducing the frequency at which the dressings have to be changed, while also reducing the exposure of the wound to the outer environment.
Kinetic concepts such as suction-encouraged tissue regeneration, microdeformation, perfusion augmentation and removal of infection are correlated benefits.
Possible side effects are wound maceration and retention of the wound’s dressing material (sponge), which could cause infection.
While there is no scientific evidence that suggests that negative pressure dressings are indispensable for ulcer healing, this therapy is always used when it is available for its guarantee of better wound cleaning and the elimination of foul odor, which contributes to creating greater comfort for the patient.
In the span of six years, from 2001 to 2007, the health care costs for negative pressure therapy pumps have increased by 600%. Although there are less expensive systems, many secondary facilities have difficulty finding the material and medical devices necessary to perform this kind of therapeutic intervention.