19
Mar, 2020

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)

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.