Pressure Ulcers Management and Surgical Intervention · Decubitus Ulcers Management and Surgical Intervention ... • 67 YOF who initially presented with epigastric pain ... surfaces

Decubitus Ulcers Management and Surgical Intervention

Ahmed Hozain, PGY 3 Downstate Medical Center

Department of Surgery Grand Rounds May 5th, 2017

www.downstatesurgery.org

Case Presentation

• 67 YOF who initially presented with epigastric pain for 1 day duration. Found to have NSTEMI on admission. .

• PMH: ESRD, Stage 4 Multiple Myeloma • PSH: Right femur repair ~ 1 month before admission (pathologic fx)

• CT Scan showed fecalization of bowel to the distal ileum with ascites • HD # 2: increasing severe abdominal pain -> General surgery

consultation • CXR neg for free air • Concern for mesenteric ischemia • Taken to OR for Exlap - Found to have internal hernia with 60cm of

strangulated bowel. Abdomen left open. Transferred to SICU


Case Presentation – Contd. • POD 2: Found to have persistent small bowel ischemia – Further resection of Small bowel

and end ileostomy creation • POD 5: Further necrosis of terminal ileum, taken for exlap - revision of ostomy. • POD 5-15:

• Course complicated by VRE bacteremia, sepsis, significant pressor requirements, hypocoagubility, stomal bleeding, significant blood transfusion requirement, ventilator dependence, and development of intraabdominal abscess.

• POD 15: Pt found to have large 9x12 cm unstageable sacral decubitus ulcer. Thought to be infected. S/p sharp excisional debridement

• POD 15 – Evening: Significant post debridement bleeding noted which was controlled at bedside with surgicell and hemostatic stitch

• POD 15-20 – Increasing intraabdominal sepsis with development of newly resistant VRE bacteremia.

• POD 20: Decision made by family to withdraw further care. Pt ultimately expired that evening.


Case Takeaway?


Outline

• Introduction • Pathophysiology + Staging • Financial implications and Impact on quality of life • Non-Surgical management • Surgical management • Current discussions in management


Introduction

• Definitions: • Skin breakdown developing secondary to

prolonged pressure or pressure in combination with shear friction and other associated factors

• Incidence: • 2.7-9% in acute care setting vs 2.4-23% in LTAC

facilities • 60,000 mortality/yearly • Spinal cord injuries:

• 25% within 1 year • 85% lifetime incidence

• Risk factors: • Immobility • AMS • Chronic conditions and malnutrition • Race


Presenter

Presentation Notes

Immobility: applies to any pt w/ a spinal cord injury, pts who are bed bound w/ chronic conditions. Pt’s w/ MS, Leugerighs disease, dementia. A study by the university of pittsbugh found that black nursing home residents were ~ 17% more likely to develop stage 3-4 ulcer compared to whitenursing home residents

Introduction • Symptoms:

• Pain, infection, chronic disability • Psychosocial consequences:

• Loss of control of ADL • Depression • Stigmatization leading to social isolation and

decrements in health related quality of life. • Cost:

• $9.1-$11.6B/Year with addition of $43,180 to each hospital stay

• Deficit Reduction Act of 2005, section 5001(c) • Identification of high cost or high volume conditions

• By October 2008, Hospital would no longer receive payment for preventable conditions – Such as Stage III-IV Pressure ulcers from CMS


Presenter

Presentation Notes

Symptoms: Chronic disability: Psychosocial consequences are not often considered. However, patients with pressure ulcers suffer pain and suffer a loss of control over their lives. Wound care disrupts normal activities of daily life and patients often feel stigmatized. This results in lifestyle changes leading to social isolation, depression and decrements in overall health-related quality of life [53]. The extent and magnitude of psychosocial complications have not been well defined in the literature


Presenter

Presentation Notes

Commonly: Sacrum, Trochanter, ischium, heals, Back/Scapula and back of head

Pathophysiology and Staging • Pressure:

• Animal modes: • > 32mmHg prevents O2/Nutrient delivery • Muscle > Subcutaneous fat > Dermis • Irreversible damage at 70mmHG > 2 hours

• Additive Effect: • Mechanical:

• Shearing forces • Friction • Moisture • Muscle spasm

• Malnutrition • Vascular:

• Arteriosclerotic disease • Diabetes • Hypoperfusion • Anemia


Presenter

Presentation Notes

Pressure: > 32mmHg prevents O2/Nutrient delivery -> accumulation of waste products. 32mmHg is the pressure at the arterial end of the capillary and 12mmgh at the venous end. Sitting pressure >300mmhG over ischial tuberosity w/ feet unsupported. With feet supported it is 100mg.. Irriversible Shearing Forces: often 2/2 incline pt placement with muscle/sub Q fat pulled downsrds by gravity while the superficial epidermis and dermis remain fixed though contact with the external surface Friction: occurs when patients are dragged across an external surface leading to abrasions and breaks to the superficla lyer of the skin Moisture: exposure to moisture, perspiration/feces/urine The National Pressure Ulcer Advisory Panel's staging system defines stage I as intact skin with nonblanchable redness of a localized area stage II as shallow open ulcer with a red pink wound bed without slough (representing partial thickness loss of dermis) stage III as full-thickness tissue loss with visible subcutaneous fat/slough, and stage IV as full thickness loss with exposed bone, tendon, or muscles that often includes undermining/tunneling with slough/eschar.[4] A deep necrotic wound may be the first evidence of pressure-induced injury, rather than a gradual progression of an ulcer from stages 1 through 4

Hospital-acquired pressure ulcers: results from the national Medicare Patient Safety Monitoring System study. Lyder et al. J Am Geriatric Society • Retrospective review of 51,842 randomly

selected Medicare admission Jan 2006 – Dec 2007

• PU presented: 2.81 OR of mortality and 1.3 % readmission and ~ 7 days longer LOS (p< 0.05)


Presenter

Presentation Notes

Medicare patient safety monitoring system: This is a nationwide surveillance system that is designed to identify rates of specific advance events w/I the Medicare populations. Ie it looks at things like the CLAPSI, VAP, DVT The large difference between the 15% reported in the research literature and the 5.8% found in the current study may be because, when a 1-day prevalence is used, individuals with longer hospital lengths of stay are more likely to be counted. Another explanation for this difference is that the majority of prevalence studies reported are completed during hospitalization, versus the current study, which counted on PUs on admission and HAPUs. The findings from the MPSMS have also demonstrated that individuals with HAPUs have much longer hospital lengths of stay. Thus, a 1-day prevalence study (often used by hospitals to determine prevalence rates) may not be an accurate reflection of individuals who developed HAPUs during their stay Limitations: obviously this was a database review and could miss significant data points.

Initial Ulcer Evaluation • Initial staging of ulcer + Anatomic location

• Type of ulcer • Size of the Ulcer L*W*D • Evaluation for multiple ulcers or communicating ulcers • Presence of granulation tissue • Sensate vs insensate wounds

• Evaluation for infection • Cellulitis • Odor • Necrosis • Crepitus • Undermining

• Determination of predisposing risk factors

• Basic laboratory testing - Determination of coagulopathy

• Physical capacity evaluation

• Serial Imaging

• Cultures • Often swab initially to determine colonization • Colonization of 105 will limit wound healing

• Imaging • Xray vs CT vs MRI

• Next Step in management?


Presenter

Presentation Notes

Swabs: are often misleading and may indicate that a pt requires tx when they don’t. Its important to determine clinically if a wound is infected. Also, if going to perform surgery, swab prior to flaps are important as they guide post procedure antibiotics. CT imaging is helpful in diagnosing deep pelvic abscess say from fistulas that develop that could lead to significant infection. Xray: Recommend in most patients as they can tell you if there is bone breakdown or signs of infection noted. Hetrotropic Calcification:Another pathological presentation of an ischial ulcer is the development of heterotopic ossifi cation (H.O.) of the ischium secondary to chronic infection, healing of the isc hial bone, and recurrent ulceration of the ischial area. This can be detected by plain x-ray of the pelvis (Fig. 2.19 ). Even if the ulcer heals, the H.O. can cause an Increase n the bony prominence of the ischium and consequently increases the sitting pressure on the skin, which predisposes to skin breakdown and recurrent ulceration. The treatment of H.O. is excision and closure of the defect by muscle flap.

Non-Surgical Management

• Encompasses both preventative measures and effective therapies used to treat pressure ulcers.

• Often reserved for Stage I-II ulcers • Systematic review of treatment

options showed the following to improve patient outcomes

• Air-fluidized beds • Protein supplementation • Radiating heat dressings • Electrical stimulation

Pressure Ulcer Treatment Strategies A Systematic Comparative Effectiveness Review. Smith et al. Ann of Internal Medicine. 2013;159:39-50


Support Surfaces

• Multiple studies compared alternating pressure surfaces, air-fluidized beds, and standard foam mattress.

• Wound improvement was seen in patients who used air-fluidized beds

• 664 patients • Compared 3 groups • Results:

• 5.2cm2 vs 1.5-1.8cm2(p<.05) – Wound healing per week

• ER visits: 7.3% vs 10.2% and 19% (p<.05) • Evidence old, generally small sample size and

underpower • Moderate level quality

Ochs RF, Horn SD, van Rijswijk L, Pietsch C, Smout RJ. Comparison of air-fluidized therapy with other support surfaces used to treat pressure ulcers in nursing home residents. Ostomy Wound Manage. 2005;51:38-68.


Presenter

Presentation Notes

In a study from Indiana U SOM in 2005 Compared standard mattress to alternating pressure beds and air-fluidized levels

Nutrition • Multiple studies evaluated use of varying formulations for pressure

ulcer wound healing • Protein found to be overall beneficial for improved healing, however

never for complete healing alone • No studies were conclusive in the type or mode of protein delivery

• Vitamin C: • Good quality evidence showing no benefits to wound healing

• Zinc supplementation: • Insufficient evidence to draw conclusions

• No significant benefit to higher dosing of arginine based formulas



Presenter

Presentation Notes

Arginine: Modern advances in nutritional therapies have led to the specific use of arginine supplementation for protein synthesis, cell signaling through the production of nitric oxide, and cell proliferation through its metabolism to ornithine and to polyamines. Arginine is classified as a nonessential amino acid that becomes a conditionally essential substrate in stressed adults. Arginine has been shown to enhance wound strength and collagen deposition in artificial incisional wounds in rodents and humans.

Disease-Specific, Versus Standard, Nutritional Support for the Treatment of Pressure Ulcers in Institutionalized Older Adults: A Randomized Controlled Trial Cereda et al. JAGS 2009 • Randomized trail of 28 patients

• 15 receiving standard nutrition (16% calories from protein

• 13 receiving enriched (20% with zinc, vitamin C, arginine supplementation)

• Outcomes: • Ulcer healing using the Pressure Ulcer Scale for

Healing (PUSH) • Results:

• Significantly improved outcomes in wound healing rate at 8 and 12 weeks in treatment group

• Significantly improved PUSH score by week 12


Presenter

Presentation Notes

Both groups of pt received 30Kcal/day of nutriotn regardless of type given. Exclusion of pts w/ acute illness, chornic disese (DM, PVD, autoimmune or neoplastic disorders) PUSH: This tool assigns subscores according to surface area (length width), exudate amount, and tissue type in the ulcer bed. Thus, a final total score categorizes lesion severity through a scale ranging from 0 (completely healed) to 17 (greatest se- Verity. They also used the Norton score in addition to limit interobserver bias. Which is used to offset difference in pt baseline chharacteristics

Local Wound Applications

• Overall there is no significant difference in complete wound healing when comparing types of local wound applications

• Systematic review of 89 original studies reviewing 7,115 patients

• Hydrocolloid gauze dressing • Radiant heat dressings • Phenytoin dressings • Debriding enzyme agents



Presenter

Presentation Notes

Hydrocolloid adhesive dressing: They absorb water and LMW components from ulcer secretions to produce a jelly which in turn leads to less mosiure. The jelly also leads to a layer of protection allowing ulcers to heal and granulate. The jelly is also thought to lead to immune system activation of granulocyts and monocytes to improve wound healing and bacterial decolonization Radiant heat though to improve blood flow and moisture to the wound leading to better wound healing Phenytoin dressings: Sought to be helpful in impmroving wound healing > 40 years ago and has been used war sounds, venous stais and burn ulcers . MOA thought o be 2/2 ecreased serum corticosteroids and the acceleration of collagen and firbin in ulcer area and theh stimulation of alkaline phosphahtase secretion. Debriding enzyme agents: collagenase, silver alginate Silver: thought o be antimicrobial leading to less biofilms and alignate thought to improve binding of MMP, TNF, Interlucins and other free radical leading to

Used, Yet Unproven Treatments

• Addition of: • Vitamin E • Anabolic steroids • Baclofen, Dantrolene, Cannabis – Antispasmodic agents • Electrical Stimulation • Electomagnetic Therapy • Therapeutic US • Negative Pressure wound therapy • Hydrotherapy • Light Therapy • Laser therapy


Presenter

Presentation Notes

Electrical stimulation therapy: is thought to be when electrical signals are applied to the ulcer and surrounding tissue to stimulate activity and increase wound healing Electromagnetic: thought to improve and stimulate migratory, proliferative and syntehic fuction of fibroblast and growth factors in the wound Theraputic US: Ultrasound therapy causes mechanical vibrations, from high frequency sound waves, on skin and soft tissue via an aqueous medium. The transducer head converts power from the generator into acoustic power that can cause thermal or non-thermal effects .[1] Negative pressure dressing: A Cochrane review of the literature looked at a total of 4 RCT comparing NPWT to other treatments with 149 patients and found that the trials were small, there were no exact outcomes defined, unclear duration of tehh study and that all studies were of poor quality and no conclusions could be drawn from them Hydrotherapy: remains an active component of wound care as a means for the removal of necrotic cellular debris and contamination. Laser and Light therapy: This treatment allows for alteration of the healing process at a cellular level. While it is not exactly clear how this type of therapy works, it is thought to diminish inflammation by reducing the number of cellular chemicals and enzymes linked to pain and inflammation.

Surgical Management

• There are no clear criteria for selecting patients to undergo surgical closure, however there are guidelines.

• Generally surgery is reserved for: • Stage III-IV • Pressure ulcers extending into bone or joints or

those causing osteomyelitis • Complications from open wounds • Acute ulcer development in otherwise healthy

patients • Ulcers which limit quality of life

Surgical Treatment of Pressure Ulcers. Sorensen JL et al. Am J Surgery. 2004


Presenter

Presentation Notes

Open wound that extend into the hip join or uretha often present common ulcer that require surgical management Patients that are post spinal cord injury those w/ acute trauma that develop ulcers and require rehabilitation. They often require reconstruction as they are insensate leading to inability to relieve pressure Pt’s who are debilitated are often candidates for debreidment, however not reconstruction. Antibiotics are routelinly given after flpa closure for 5 days post procedure Stage 3-4 ulcers lact large amounts of stiff and scanty scar tissue which can result in poor wound healing.

Direct Closure and Skin Grafts

• Direct closure: • Rarely ever indicated • High rate of recurrence and dehiscence

• Skin flaps • Reserved for well granulated wounds • Requires pressure offloading for 3 weeks • Split vs full thickness grafts


Presenter

Presentation Notes

Colostomy placement

Plastic Surgery - Skin Flaps

• Categorized based on type of vascular supply or type of tissue in flap.

• Cutaneous Flap • Fasciocutaneous flaps • Myocutaneous flaps • Muscle flaps

• Type of flap transfer: • Rotational flap • Advancement flap • Transportion flap • Regional Flap • Free Flap


Presenter

Presentation Notes

Sensate flaps:

Flap Management of Sacral Pressure Ulcer • Gluteus Maximus muscle most

commonly used for repair • Recommended for non-

ambulatory patients • Detachment of gluteus muscle

leads to functional impairment • Dual blood supply

• Superior and inferior gluteal artery and the medial circumflex

• Originates from lumbar fascia and inserts into the greater trochanter.

• External rotation and extension of hip joint

• Rotation flap, Advancement island flap and splitting transposition flaps.


Presenter

Presentation Notes

This fl ap is not recommended for ambulatory patients because the lower attachment of the gluteus muscle is detached, which can result in functional loss. -Pts w/ previous spinal injhuries are at hight risk for damage to the superior gluteal artery secondary to theh dissection in extensive scarring caused by previous surgery. -

Advancement Flaps


Post Operative Care and Complications • Post Op Care:

• Focus on reliving pressure, Antibiotics and supplementary measures for wound healing

• Infection • Very common • Bacterial contamination • Colostomy

• Vascular compromise • Tension • Previous surgery

• Muscle Spasm: • Can lead to shearing force development

• Development of seroma/Hematoma • Flap necrosis


Presenter

Presentation Notes

Chronic open wounds; Contamination 2/2 stool or previous colonization Seroma: Management is aggressive irritgation of theh space under the flap w/ saline and packing

Long-Term Outcome of Pressure Sores Treated with Flap Coverage Yamamoto Y et al. Plastic and Reconstructive Surgery 1997

• Review of Non-randomized 45 ischial and 24 sacral pressure ulcer patients from 1990 to 1995

• Analyzed types of flap used • Sacrum: 23 patients underwent

Fasciocutaneous flap, 1 myocutaneous • Ischium: 18 patients underwent

fasciocutaneous flaps and 30 myocutaneous flaps.

• Outcomes: %PSFS • Results: 49% overall in Fasiocutaneous vs

63% in myocutaneous flaps.


Presenter

Presentation Notes

PsfS: Pressure sore free survival The suspected reason is that the muscle becomes very atrophic and necrotic in some angimal modesl secondary to disuse. This leads to higher rates of recurrence and breakdown of theh wound. A follow up study performed in belgum showed no signifncat difference in type of flap used and no differnces on long term follow up in wounds that were closed w either myocutanoues vs fasciocutatnous flaps. Their recurrence rate

A systematic review of complication and recurrence rates of musculocutaneous, fasciocutaneous, and perforator-based flaps for treatment of pressure sores. Sameem M et al. Plast Recon Surg 2002

• Inclusion criteria: • Examination of myocutaneous, fasciocutaneous, and/or perforator based flaps • Examination of pressure sores: Sacrum, Ischium, trochanteric regions

• Outcome measures: • Overall complications • Recurrence rates

• Results: • 55/894 articles reviewed

• 28 evaluating myocutaneous flaps – Overall recurrence rate of 8.9% • 13 evaluating fasciocutaneous flaps – Overall recurrence rate of 11.2% • 14 evaluating perforator flaps – Overall recurrence rate of 5.6% • No statistical difference overall in complications/recurrence rates


Presenter

Presentation Notes

Study from the University of Tornoto Complications looked at dehiscence, infection, necrosis, and others This study was ultimately still limited however by small smaple size, most studies looked at patients w/ 10-65 partipicatps. Moreseo, there was significant heterogeneity between studies which hwas noticble in the analysis.

Complications of Myocutaneous flaps

Complications of Fasciocutaneous flaps

Complications of Perforator flaps


Final Thoughts • Pressure ulcers are expensive

complications which are preventable with appropriate care

• All ulcers need to be staged for appropriate management

• Treatment of pressure ulcers is MULTIFACTORIAL and requires both surgical and non-surgical options

• If you feel uncomfortable with wound debridement: Please ASK your senior residents to supervise you


Thank You www.downstatesurgery.org

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Pressure Ulcers Management and Surgical Intervention · Decubitus Ulcers Management and Surgical Intervention ... • 67 YOF who initially presented with epigastric pain ... surfaces