Pressure ulcer (Decubitus ulcer)

Notes

## Basic introduction

  • Pressure ulcer (PrU) or decubitus ulcer is a skin lesion caused by unrelieved pressure resulting in damage to soft tissue compressed between a bony prominence and external surface over a prolonged period of time[a]
  • Risk factors for PrU[a][b][d]:
  • Common in old age due to:

||| Decreased subcutaneous fat

||| Decreased local blood supply to the …skin

||| Flattened epithelial layers

||| Loss of elasticity of collagen fibers

||| Reduced tolerance to hypoxia

  • Decreased arteriolar blood pressure
  • Decreased mobility
  • Diabetes
  • AIDS
  • Fecal incontinence
  • Friction
  • History of PrU
  • Low BMI
  • Mental status of the patient
  • Moisture (dry skin as well as wet skin increases risk)
  • Neurologic diseases e.g. dementia, delirium, spinal cord injury, and neuropathy
  • Nutritional compromise
  • Reduced mobility
  • Sensory perception especially in regards to having ability to respond to pressure-related discomfort
  • Skin perfusion (increased)
  • Spinal injury (quite common, mainly paraplegia)
  • Stroke
  • Urinary incontinence
  • Underlying diseases such as anemia and CHF among others
  • European Pressure Ulcer Advisory Panel (EPUAP) Grading Tool[b]:
  • Grade 1

||| Non-blanchable erythema of intact     …skin

||| The skin is discolored

||| The skin may be warm

||| Edema

||| Induration

  • Grade 2

||| Partial thickness skin loss of epidermis, dermis, or both

||| Superficial ulcers

||| The ulcer may look like an abrasion or a blister.

  • Grade 3

||| Full thickness skin loss

||| Necrosis of subcutaneous tissue

  • Grade 4

||| Extensive destruction

||| Necrosis extending to muscle, bone and supporting structures

  • Unstageable (depth unknown)

||| Full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed

  • Stages of development of PrUs:
  • Stage 1: Hyperemia

||| Observed within 30 minutes or less

||| It is manifested by redness of the skin, which disappears within one hour after the pressure is removed

  • Stage 2: Ischemia

||| Develops if pressure is continuous for 2-6hrs

|||Redness that may take >36hrs after pressure is relieved to disappear

  • Stage 3: Necrosis

|||Pressure not relieved within 6 hrs

|||Blueness of the skin for the white skinned people or a hard lump similar to a boil in dark skinned people

||| These symptoms do not disappear after pressure is relieved.

  • Stage 4: Ulceration

||| Necrotic area are ulcerated and infected within a period of about 2wks

||| Bony prominence are most affected

  • The most common sites of PrUs are:
  • Sacrum (tail bone) is the most common site
  • Heel is the 2nd most common site
  • Trochanter (hip bone)
  • Ischium (sitting erect bone)
  • Pathophysiology of PrU include:
  • Pressure being exerted by bony prominences on the body
  • This stops capillary flow to the tissues
  • The tissues are deprived of oxygen and nutrients causing cell death.
  • Complications of PrUs include:
  • Sepsis
  • Cellulitis
  • Osteomyelitis
  • Cardiopulmonary complications
  • Depression
  • Hemorrhage
  • Heterotrophic calcification
  • Pain
  • Sinus tracts (which are linked to the deep viscera such as the bowel and bladder)
  • Squamous cell carcinoma
  • Systemic amyloidosis

## Statistics

  • The prevalence of PrUs globally is estimated to be 3-5% of all hospitalized patients[e]
  • 60% of old people who develop PrUs within 1yr of hospital discharge die
  • 20% of all PrUs occur on the heels (hence special care is required to prevent this)
  • A study by Jenkins and O'neal (2010) in California (USA) found that the prevalence of PrU among the acute-care patients was 12-19.7% with the most common PrU sites being the heel (26%), the coccyx (20%), and the ear (19%)[c]
  • A study by Nang’ole et al. (2009) at Kenyatta National Hospital and the Spinal Injury Hospital in Kenya established that the commonest anatomical site of PrUs was the tronchanter (43%) and most of PrUs (97.2%) were below the umbilicus. Most of the PrUs were also in Grade 3 & 4 (66.4%) stages.
  • In the same study, Nang’ole et al. (2009) established that gauze dressing was the most commonly used dressing method with povidone iodine being the most commonly used antiseptic (67.3% of all cases).
Symptoms
  • Ulcers in areas that are subjected to pressure
Diagnosis
  • Clinical review
Differential
  • Moisture lesion
  • Ulcers from diabetic neuropathy
  • Ulcers from arterial or venous insufficiency
Prevention
  • Mechanical loading;
  • Turning and repositioning the patient (at least once after 2hrs or 15 minutes if on wheel chair) and using the right approach
  • The head of the bed should be repositioned at the lowest possible elevation
  • A pillow can be placed under the legs to keep the heels off the bed
  • Air or water static floatation (or mattress) can reduce pressure and shear forces on the potential areas for the PrU
  • Though costly, dynamic support surfaces such as fluidized air, low air loss and alternating air mattresses are more effective than static support surfaces in reduction of pressure, heat accumulation and shear forces on the potential areas for the PrU
  • Nutrition
  • Reduction of friction and shear forces by:
  • Regular use of lubricants or protective films
  • Proper dressings and padding
  • Proper skin care such as:
  • Regular inspection of the skin (paying special attention to the bony prominences)
  • Moisturizing the dry skin
  • Reduce wetness e.g. from incontinence, perspiration and drainage
  • Avoid massaging of the bony parts of the body.
Reference
  1. Berlowitz, D. (2012). Pressure ulcers: Epidemiology, pathogenesis, clinical manifestations, and staging. Available Source: http://www. Uptodate. com.
  2. Beeckman, D., Schoonhoven, L., Fletcher, J., Furtado, K., Gunningberg, L., Heyman, H., ... & Defloor, T. (2007). EPUAP classification system for pressure ulcers: European reliability study. Journal of advanced nursing, 60(6), 682-691
  3. Jenkins, M. L., & O'neal, E. (2010). Pressure ulcer prevalence and incidence in acute care. Advances in skin & wound care, 23(12), 556-559.
  4. Nangole, F. W., Khainga, S. O., & Kiboi, J. (2009). Pressure ulcers presentations and management at Kenyatta National Hospital and Spinal Injury Hospital. East African Medical Journal, 86(12), 545-550.
  5. Young, J. B., & Dobrzanski, S. (1992). Pressure sores. Drugs & aging, 2(1), 42-57.
  6. Galpin, J. E., Chow, A. W., Bayer, A. S., & Guze, L. B. (1976). Sepsis associated with decubitus ulcers. The American journal of medicine, 61(3), 346-350
  7. Hirschberg, J., Coleman, J., Marchant, B., & Rees, R. S. (2001). TGF-β3 in the treatment of pressure ulcers: a preliminary report. Advances in skin & wound care, 14(2), 91-95
Management
  • Protective measures
  • Antibiotics like clindamycin or gentamycin in case of bacterial infections
  • Vitamin C supplements
  • Topical anti-microbial like silver sulphadiazine and triple antibiotics
  • Surgical management of PrUs is apparently the best method of management of Grade 3 and Grade 4 PrUs in resource constrained countries (where effective materials e.g. VAC dressings, are not affordable to many)[d]. The most common surgical procedures in the treatment of PrUs are[d]:
  • Fasciocutaneous flaps (81.7%)
  • Myofasciocutaneous flaps
  • V-Y plasty
  • Skin grafts.
  • Debridement can be done by using:
  • Surgical sharps like scissors
  • Enzymatic debriding agents like collagenase, trypsin, papain, fibrinolysin- deoxyribonuclease
  • Biosurgery (such as larva / maggots to feed on dead tissues)
  • Mechanical method of wet and dry irrigation
  • Autolytic method (where the dead tissues are left alone to auto digest)
  • Polyurethane film dressing
  • Absorbent hydrocolloid dressing
  • Tumour growth factor beta 3 (TGF-beta 3)[g]
  • Calendula ointment or 5% flower extract to stimulate new epithelial growth
  • Marsh mallow
  • Clean often when purulent or foul-smelling drainage appears
  • Topical antiseptics may cause tissue toxicity
  • 75% topical metronidazole gel is thought to help in control of odor associated with PrUs[f]
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