Pressure Ulcers: 3 Keys to Pressure Ulcer Management. Evidence Based Prevention & Management. I have no financial conflicts of interest

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1 Pressure Ulcers: Evidence Based Prevention & Management Madhuri Reddy, MD MSc I have no financial conflicts of interest I have nothing to disclose financially 3 Keys to Pressure Ulcer Management 1

2 3 Keys to Pressure Ulcer Management TREAT THE CAUSE PATIENT-CENTRED CONCERNS LOCAL WOUND CARE Sibbald et al,ostomy/wound Mgmt,2000 More than a 1000 wound products available Don t need proof of efficacy in order to market many wound products Financial conflict of interest in published studies Reddy et al, JAMA 2008;300(22) What are the major causes of wounds? ACUTE CHRONIC Trauma Burns Pressure Diabetic Venous stasis Peripheral vascular disease Other (e.g. poorly healing post-surgical; dehiscence; pyoderma gangrenosum; vasculitic; malignant) 2

3 Chronic Wounds: Impaired healing - Inflammation - Matrix metalloproteinases (MMPs) - Protease inhibitors - Surface growth factors Eming et al, J Invest Derm, 2007 Unfortunately, advanced wound therapies have not worked as well as we had hoped. So what now? 3

4 Case: Mr. H.M. 72 y.o. Male; PMHx of cardiac disease, TIAs; no diabetes, nonsmoker Admitted to hospital with left heel ulcer & systemic symptoms Left Below Knee Amputation: July 21, 2008 Discharge from hospital: July 30, 2008 At time of discharge, small blister, with no break in the skin on his Right heel Came to wound clinic: Sept 13, 2008 The BEST non-invasive method of detecting adequate vasculature for wound healing is: Feeling for a palpable pulse Doppler assessment of ankle-brachial index (ABI) Transcutaneous oxygen tension (tco2) Toe photoplethysmography (PPG) Lower leg arterial doppler Angiography 4

5 Is there enough blood supply for the wound to heal? Toe Pressure > 50 mmhg ABI > 0.5 TcO 2 > 30 mmhg Palpable Pulse 80 mmhg Ann Vasc Surg 1996; 10:224-7 Improving Vascularity Microscopic distal surgery now an option popliteal-to-distal bypass for limb salvage (Ann Vasc Surg, 2004) dorsalis pedis artery bypass (J Vasc Surg, 2003) Pressure Ulcer Causes 5

6 Pressure Tolerance Guidelines Maximum suggested pressure/ time application over bony prominences Unacceptable Acceptable Hours of continuous pressure A pressure ulcer can occur within 3 hours of lying on an ER stretcher versus What type of mattress should I suggest and does it matter anyway? 6

7 There are really only 2 categories of mattress Non-powered Filled with air, water, gel, foam or a combination of these Powered mechanically vary the pressure beneath the patient & thereby reduce the duration of the applied pressure $$$$$$$$$$ National Pressure Ulcer Advisory Panel 2007 Wheelchair Cushions Pressure Mapping 7

8 Support Surface Recommendations Non-powered specialized mattresses throughout facilities Powered mattresses or overlays for those with deep (Stage III-IV) pressure ulcers Overlays for operating room tables Reddy et al, JAMA 2006; 296(8) McInnes, Cochrane Database of Systematic Reviews 2008 For Outpatients All patients in wheelchairs All older patients with limited mobility (ie. OA, RA) 1. OT home seating assessment 2. OT home safety assessment 3. Referral to wheelchair clinic q2yrs 4. Referral to wound clinic 3 Keys to Pressure Ulcer Management TREAT THE CAUSE PATIENT-CENTRED CONCERNS LOCAL WOUND CARE Sibbald et al,ostomy/wound Mgmt,2000 8

9 Local wound care: What dressing do I use? HEALABLE? Must decide which category the wound is most likely to fall into: MAINTENANCE? NON-HEALABLE? Wounds with the Ability to Heal Local wound care Moisture Balance Debridement Bacterial Balance Sibbald et al, Adv Skin Wound Care, 2006 Maintenance & Non-Healable Wounds Moisture Balance Local wound care Bacterial Balance Debridement In a wound that does not have the ability to heal, moisture balance and active debridement are of no benefit and may be extremely harmful. Topical antiseptics will decrease local bacterial counts and subsequent invasion of organisms into proximal viable tissue Sibbald et al, Adv Skin Wound Care, 2006 Schultz et al, Wound Rep Regen, 2003 Banwell et al, Dermatology,

10 Wound Dressings: think FUNCTION Combination (Moisture balance, Bacterial balance & Debridement): cadexemor iodine, silver dressings Moisture balance: foams, alginates Bacterial balance: silvadene; antiseptics if non-healable or maintenance is the goal Debridement: gels, enzymatic agents (eg. collagenase, papain-urea) van Rijswijk. J Wound Care 2006 Ovington, Peirce. In: Chronic Wound Care 3 rd Ed Common Contact Allergens Lanolin Rosin (colophony) Propylene glycol Parabens Formaldehyde Benzocaine Neomycin, bacitracin Rubber Perfume Lubricants, tulle dressings, topical antibiotic creams Adhesives Preservatives, lubricants Preservatives Preservative, cleansers Local anesthetic creams Topical antibiotics Latex products, ostomy products, elastic Lubricants, masked scents Gehrig, Warshaw. JAAD 2008 Jankićević et al. Contact Dermatitis 2008 Saap et al. Arch Dermatol 2004 Little evidence to support a specific dressing over other alternatives adjunctive therapies (including vacuum therapy or hyperbaric oxygen) compared with standard care Reddy et al, JAMA 2008;300(22) 10

11 Should this eschar be debrided? YES, DEFINITELY NO WAY Should this eschar be debrided? It depends What method of debridement is best? Sharp Surgical: scissors, scalpel Autolytic: hydrogels Enzymatic: collagenase Mechanical: whirlpool, maggots No debriding agent has been found to be consistently superior Edwards J, Cochrane Database of Systematic Reviews 2007 Bradley et al,health Technol Assess. 1999;3(17 Pt 1):iii-iv 11

12 When Infection doesn t look like Infection Unfortunately infection is not always obvious Friable granulation tissue Easily bleeds Exuberant granulation Pain Not healing despite adequate treatment Butalia et al, JAMA 2008; 299 Lindholm. Ostomy/ Wound Mgmt 2003;49 (5A suppl) Grayson et al, JAMA 1995; 273 Gardner et al. Wound Repair Regen 2001;9 Probes to bone? Osteomyelitis until proven otherwise Butalia et al, JAMA 2008; 299 Grayson et al, JAMA 1995; 273 >3º F difference between 2 mirror sites Infrared Thermometer Differential Diagnosis: 1. INFECTION 2. UNEQUAL VASCULATURE 3. CHARCOT FOOT 12

13 I. TREAT THE CAUSE Use appropriate support surfaces Positioning supine: pillows to suspend heels above mattress if not effective: consult PT/OT lateral turns < 30 degrees; HOB < 30 degrees prone position if patient can tolerate Optimize nutritional status consult dietician no evidence to oversupplement Moisturize sacral skin Is there an additional contributing cause for this wound (e.g. poor arterial flow)? II. PATIENT-CENTRED CONCERNS Determine whether or not the wound is likely to heal (i.e. goals of care) III. LOCAL WOUND CARE Moisture balance, bacterial balance, debridement Reddy et al, JAMA 2006; 296(8) Reddy et al, JAMA 2008;300(22) Role of Surgery Deep pressure ulcers (stage III-IV) Carefully select patients: reversible risk factors have the best outcome Surgery fails 39-60% of the time Schryvers et al, Arch Phys Med Rehabil. 2000; 81(12) Pressure Ulcer Treat Cause Local Wound Care Patient-Centered Concerns Debridement Bacterial Balance Moist Interactive Healing Non-healing Wound?Adjuvant treatments?biological Agents 13

14 Thank You 14