DEEP TISSUE INJURY IN THE BARIATRIC POPULATION James G. Spahn, MD, FACS 1 DEFINITION Bariatrics The field of medicine that offers treatment for the person that is overweight. 2 HOW IS OVERWEIGHT DEFINED? The body mass index (BMI) is a commonly used measurement tool to define heavy weight, overweight and obesity. BMI is calculated by multiplying weight (in pounds) by 703 and then dividing by the height (in inches squared). 3
CLASSIFICATIONS FOR BMI Underweight: Lower than 18.5 Normal weight: 18.5 to 24.9 Overweight: 25 to 29.9 Obesity: 30 to 34.9 (class 1) Obesity: 35 to 39.9 (class 2) Extreme Obesity: Greater than 40 (class 3) National Heart and Lung Institute 4 HEALTH CONSEQUENCES OF OBESITY Coronary heart disease Type 2 diabetes Cancers (endometrial, breast and colon) Dyslipidemia Stroke (high blood pressure) Liver and gallbladder disease Sleep apnea and respiratory problems Osteoarthritis Gynecological problems (abnormal menses, infertility) American Society of Bariatric Physicians 5 WHAT S MISSING? Wounds 6
WHAT TYPE OF WOUNDS? Pressure Ulcer Vascular Ulcer - Arterial/Ischemic - Venous - Lymphatic Neuropathic Trauma Surgical Other 7 PRESSURE ULCER STAGES REVISED BY NATIONAL PRESSURE ULCER ADVISORY PANEL (NPUAP) February 2007 The National Pressure Ulcer Advisory Panel has redefined the definition of a pressure ulcer and the stages of pressure ulcers, including the original 4 stages and adding 2 stages on deep tissue injury and unstageable pressure ulcers. The work is the culmination of over 5 years of work beginning with the identification of deep tissue injury in 2001. Pressure Ulcer Definition A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Pressure Ulcer Stages Revised by National Pressure Ulcer 8 Advisory Panel (NPUAP) PRESSURE ULCER STAGES REVISED BY NATIONAL PRESSURE ULCER ADVISORY PANEL (NPUAP) Pressure Ulcer Stages Suspected Deep Tissue Injury: Purple or maroon, localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Further description Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar.evolution may be rapid exposing additional layers of tissue even with optimal treatment. Pressure Ulcer Stages Revised by National Pressure Ulcer 9 Advisory Panel (NPUAP)
PRESSURE ULCER STAGES REVISED BY NATIONAL PRESSURE ULCER ADVISORY PANEL (NPUAP) Stage I Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from surrounding area. Further description The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate at risk persons (a heralding sign of risk) Stage II Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also be present as an intact or open/ruptured serum-filled blister. Further description Presents as a shiny or dry shallow ulcer without slough or bruising*. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. * Bruising indicates suspected deep tissue injury. Pressure Ulcer Stages Revised by National Pressure Ulcer Advisory Panel (NPUAP) 10 PRESSURE ULCER STAGES REVISED BY NATIONAL PRESSURE ULCER ADVISORY PANEL (NPUAP) Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling Further description The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Stage IV Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Further description The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (eg. Fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible and directly palpable. Pressure Ulcer Stages Revised by National Pressure Ulcer Advisory Panel (NPUAP) 11 PRESSURE ULCER STAGES REVISED BY NATIONAL PRESSURE ULCER ADVISORY PANEL (NPUAP) Unstageable Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Pressure Ulcer Stages Revised by National Pressure Ulcer Advisory Panel (NPUAP) 12
PRESSURE ULCER STAGES REVISED BY NATIONAL PRESSURE ULCER ADVISORY PANEL (NPUAP) The staging system was defined by Shea in 1975 and provides a name to the amount of anatomical tissue loss. The original definitions were confusing to many clinicians and lead to inaccurate staging of ulcers associated or due to perineal dermatitis and those due to deep tissue injury. The proposed definitions were refined by the NPUAP with input from an online evaluation of their face validity, accuracy clarity, succinctness, utility, and discrimination. This process was completed online and provided input to the Panel for continued work. The proposed final definitions were reviewed by a consensus conference and their comments were used to create the final definitions. NPUAP is pleased to have completed this important task and look forward to the inclusion of these definitions into practice, education and research, said Joyce Black, NPUAP President and Chairperson of the Staging Task Force. Pressure Ulcer Stages Revised by National Pressure Ulcer Advisory Panel (NPUAP) 13 MAGNITUDE OF OBESITY 14 Magnitude of the Pressure Ulcer Problem 15
Despite the publication of clinical practice guidelines addressing pressure ulcer prevention and treatment by the Agency for Health Care Policy and Research (AHCPR) within the past decade, the length of stay and cost associated with pressure ulcers continues to rise. The Agency for Health Research and Quality (AHRQ) released a survey showing a 63% increase in pressure ulcer occurrence in acute care hospitals from 1993 to 2003 (Russo, 2006) Whittington K, Patrick, M, Roberts JL. A national study of pressure ulcer prevalence and incidence in acute care hospitals. JWOCN2000;27(4):209. Allman RM, Goode PS, Burst N, Bartolucci AA, Thomas DR. Pressure ulcers, hospital complications, and disease severity: impact on hospital costs and length of stay. Adv Wound Care 1999; 12:22-30. Hospitalizations Related to Pressure Sores, 2003 C. Allison Russo, MPH and Anne Elixhauser, PhD H-Cup Statistical Brief #3 16 MAYBE... Keep it Simply Scientific 17 KEEP IT SIMPLY SCIENTIFIC Physiology is the bridge between basic science and clinical medicine. Basic Science Anatomy Macro Micro Cellular Biology Chemistry Inorganic Organic Mechanics Static Dynamic Physics Clinical Medicine Healthy state Homeostasis Unhealthy state Disease 18
KEEP IT SIMPLY SCIENTIFIC Physiology 19 HOMEOSTASIS Wisdom of the Body Walter Cannon, early 1900 s 20 HOMEOSTASIS The body s ability to maintain relatively stable internal conditions even though the outside world changes continuously. 21
SUPPORTING SURFACE = OUTSIDE WORLD VARIABLE Effect Cause HOMEOSTASIS Marieb EN. Human anatomy & physiology. Menlo Park (CA): Benjamin/Cummings; 1998 22 The body is supported by a hard framework The body is 3-Dimensional 23 THE CULPRIT? Body Weight (Skeletal Press) Weight = Gravity x Mass Tissue at Risk (Viscoelastic Soft Tissue) Support Surface (Media, Container Design) GRAVITY 24
SOFT TISSUE AT RISK Epithelial - covering + skin-epidermis/dermis + endothelium-lining of the vessels Adipose tissue Connective - support Muscle - movement Nervous - control 25 WHAT AFFECTS PROFUSION Decreased perfusion pressure Cardiovascular disease Shock Soft tissue shape deformation (distortion) Intraluminal obstruction (emboli-clots) Increased capillary closing pressure External Mechanical stress (gradient pressure or shear) Internal Edema Clotting Venous hypertension Soft tissue shape deformation (distortion) 26 EVEN MINIMAL DISTORTION CAN BE DISRUPTIVE TO HOMEOSTASIS BALANCE Hemodynamics Cardiovascular status Size of vessels Health of vessels Direction of vessels 27
NORMAL INFLAMMATORY RESPONSE Normal Inflammatory Response Chemotaxis secondary to cell death Margination of neutrophils No endothelial damage Diapedesis Migration Phagocytosis Rhoades R, Pflanzer R. Human Physiology. USA: Saunders; 1996 28 NORMAL INFLAMMATORY RESPONSE Rhoades R, Pflanzer R. Human Physiology. USA: Saunders; 1996 29 ETIOLOGY OF PRESSURE ULCERS Adapted from Petillo M, ed., Mondoux LC ed, The Nursing Clinics of North America: Enterostomal Therapy/Pressure ulcers 30 Philadelphia, (PA) Saunders; 1987
31 PRESSURE ULCER DEVELOPMENT Pathophysiology Mechanical stress (Gradient pressure or shear) Soft tissue distortion Change in velocity or character of blood flow Margination of intravascular cells Endothelial Damage Intravascular coagulation Decreased oxygen Anaerobic metabolism Ischemia Necrosis Inflammatory Response Homeostasis Imbalance Rhoades R, Pflanzer R. Human Physiology. USA: Saunders; 1996 32 Normal Laminar Blood Flow Turbulent Blood Flow 33
Margination - Endothelial Damage & Capillary Permeability 34 Stasis and Clotting Capillary Micro-Thrombotic Event 35 ENDOTHELIAL DAMAGE Cause Intravascular cell margination Enzymatic and oxygen free radical injury Result Loss of smoothness Loss of glycocalyx- thrombomodulin layer Effect Activation of Factor XII and platelets with initiation of intrinsic pathway clotting Damage to vascular wall activates extrinsic pathway clotting Increased capillary permeability Pressure Ulcer Focus 2000? 36
POTENTIAL OUTCOMES ASSOCIATED WITH BLOOD FLOW INTERRUPTION No restoration of blood flow Return to normal blood flow with no damage Return to blood flow with reperfusion injury 37 DEFINITION OF REPERFUSION INJURY Post-ischemic tissue injury caused by highly reactive oxygen free radicals (Oxidative reaction imbalance) Predisposing factors Age Malnutrition Protein/calorie Vitamin/mineral Cellular injury Hyperinflammatory response 38 KNOW THE EFFECT OF THE SUPPORT SURFACE ON THE SOFT TISSUE AT RISK Unequalized Weight Distribution 39
KNOW THE EFFECT OF THE SUPPORT SURFACE ON THE SOFT TISSUE AT RISK Equalized Weight Distribution (FLOTATION THERAPY) 40 MECHANICAL STRESS Pressure Load perpendicular to the plan of interest. Shear Load parallel to the plane of interest. Friction Tendency of two objects to stick together Compression Distortion Distortion Soft tissue responds to mechanical stress in either distortion or volumetric support. 41 GRADIENT VS NON-GRADIENT PRESSURE 42
HORIZONTAL SHEAR VERTICAL SHEAR (GRADIENT PRESSURE) 43 BASIC SCIENTIFIC PRINCIPLES RELATING TO MECHANICS AND PHYSICS EXPLAIN THE EFFECTS OF VARIOUS SUPPORT SURFACES Basic physics 200 BC Archimedes 17th Century Boyle Pascal Newton Hooke s Young s Modulus Shear Modulus Bulk Modulus Physical properties of media Static (non-powered) Gas minimal molecular bonding Liquid moderate molecular bonding Solid strong molecular bonding Dynamic (powered) Fluid Gas 44 PHYSICAL PROPERTIES OF MEDIA 45
ALL CONTAINERS ARE SOLID, THUS THE DESIGN OF THE CONTAINER IS VERY IMPORTANT. Pliable compliment the physical Flexible properties of the media Durable}Must 46 PRESSURE & SHEAR VECTOR Since the human body is 3-dimensional Then Deliverance of gradient pressure and shear mechanical stresses by the support surface (solids, gels, and powered fluids) Will Cause soft tissue distortion, change in velocity and flow pattern of the circulation, causing endothelial damage resulting in ischemia and possible infarction of the soft tissue at risk (pressure ulcer) Thus Selection of these types of media must be evaluated by scientific facts and soft tissue strain visualization (CT or MRI scanning) since pressure mapping is 2-dimensional and unreliable in defining causation of soft tissue distortion 47 If the human body is 3-dimensional PRESSURE & SHEAR VECTOR Then Volumetric support is needed to maintain proper tissue orientation Then A static fluid media (gas, liquid, sol) is needed to float the body in a flexible container that is properly filled or inflated And Static air is preferred to liquid or sol because it has less density and no viscosity FLOTATION THERAPY Equalized distribution of the body s weight 48
DEFINITION OF A CLINICAL FLOTATION DEVICE Supports a 3-dimensional body in a pliable solid container filled with a static fluid media. 49 RESULT OF A WELL-DESIGNED FLOTATION THERAPY DEVICE Mechanical stress = Non-gradient perpendicular pressure with minimal shear Soft tissue strain = Volumetric support with minimal distortion 50 FLOTATION THERAPY FACTS Contouring is not equal to Flotation Therapy Dynamic fluids do not deliver Flotation Therapy Overinflation or Overfilling of a static media container will not deliver Flotation Therapy 51
FLOTATION THERAPY Technology Reference -Archimedes (200 BC) -Boyle, Pascal, Newton, Hooke s (17th Century) -Manufacturing (1970-Present) Basic Research -CT scan, MRI Clinical Reference -Outcome studies Physiology Reference -Living in atmosphere (air, water) -Fetus in uterus 52 53 NATURE S FLOTATION 54
MAINTAIN AUTOREGULATION Clinical Protocols Nutrition Mobilization Ambulate Turn Passive Range of Motion Support Surface Bed, Chair, Cart, Emergency Room, Operating Room Incontinence Care Wound Care Continuum of Care Treatment of other general medical conditions DO NO HARM! 55 VARIOUS TISSUE EFFECTED BY OBESITY Integumentary system Adipose tissue Muscular system Connective tissue Skeletal system Neural system Vascular System 56 Contouring 57
58 Normal 59 60
61 62 63
64 DEEP TISSUE INJURY OCCURRING IN AREAS WITH MINIMAL SUB-CUTANEOUS TISSUE Heel Sacrum Malleous Occiput 65 66
67 DEEP TISSUE INJURY IN MODERATE TO EXTENSIVE SUBCUTANEOUS TISSUE Ischial tuberosity Lateral Gluteal Muscle In the bariatric population Muscles of the low back and buttock region Skin and soft tissue in skin folds Devices and objects against the body causing DTI 68 69
70 71 72
73 74 75
PATHOPHYSIOLOGY AND AETIOLOGY OF PRESSURE ULCER The Prevention and Treatment of Pressure Ulcers. Edited by Moya J. 76 Morrison Forward by: Lia Van Rijswijk. Mosby. Page 29 MUSCULAR SYSTEM (RHABDOMYOLYSIS) Risk factors: Preoperative Male Age greater than 40 years BMI greater than 55kg/m squared History of hypertension, diabetes mellitus, or peripheral vascular disease History of statin use Elevated preoperative serum CPK level Tanakan PT, Brodsky JB. Rhabdomyolysis Following Bariatric Surgery 2007 Bariatric times, December 2007 77 MUSCULAR SYSTEM (RHABDOMYOLYSIS) CONT. Risk factors: Intraoperative Operation duration greater than 5 hours Anesthesia time greater than 6 hours Inadequate padding of pressure areas Inadequate hydration Urine output less than 1.5ml/kg/h Bleeding and/or hypotension Use of propofol and/or succinylcholine Tanakan PT, Brodsky JB. Rhabdomyolysis Following Bariatric Surgery 2007 Bariatric times, December 2007 78
MUSCULAR SYSTEM (RHABDOMYOLYSIS) Risk factors: Postoperative Complaints of muscle pain and weakness Delayed ambulation Urine output less than 1.5mL/kg/h Serum CPK greater than 1,000 IU/L Urine myoglobin greater than 250ug/L Tanakan PT, Brodsky JB. Rhabdomyolysis Following Bariatric Surgery 2007 Bariatric times, December 2007 79 MUSCULAR SYSTEM (RHABDOMYOLYSIS) CONT. Treatment: Immediate Intravenous Diureses (mannitol, furosemide) Alkalinization (bicarbonate, acetazolamide) Correct electrolyte abnormalities Lower uric acid (allopurinol) Tanakan PT, Brodsky JB. Rhabdomyolysis Following Bariatric Surgery 2007 Bariatric times, December 2007 80 MUSCULAR SYSTEM (RHABDOMYOLYSIS) CONT. Treatment: Immediate Dialysis for renal failure Treat disseminated intravascular coagulopathy Decompress compartment syndrome Tanakan PT, Brodsky JB. Rhabdomyolysis Following Bariatric Surgery 2007 Bariatric times, December 2007 81
ADDRESS NINE RISK FACTORS 1. Cognition 2. Mobilization & Ambulation (motor and/or sensory) 3. Nutrition & Hydration 4. Moisture (excessive or dryness) & Incontinence (urinary/ fecal/combination) 5. General Medical Co-Morbidities (Medication Use) 6. Existing Pressure Ulcers (Suggested DTI, Stage I,II,III,IV,and Unstageable) 7. Previous Pressure Ulcers (Closed Stage III, IV, and Unstageable and DTI) 8. Contact with medical devices (i.e. braces, orthotics, cannulas, tubing), and/or any object in contact with the body 9. Patient chooses not to accept part or all of the suggested medical treatment References: Tag 314 Requirements Braden Scale, Norton Scale, Waterloo, ADLS, CDS AMDA Guidelines (2008) 82 FUTURE RESEARCH NEEDED Predictive Modeling High Frequency Ultrasound Thermography Other 83