Thursday, 8 December 2011

Pressure Ulcers

Pressure Ulcers or Decubitus Ulcers arise as a result of prolonged period of lying down on a bed as in paraplegics or sitting on wheelchairs. They arise in prominent, bony areas. The severity is staged, depending on the depth of the ulcer:

Stage 1 - Redness of the overlying skin
Stage 2 - Subcutaneous fat layer (fat layer under the skin)
Stage 3 - Muscle sheet & muscle
Stage 4 - Bone

The causes can be:

1. Direct damage to the skin surface
a/ Friction to the skin surface
b/ Chemical burns

2. Interference with blood supply to the skin from below
a/ Local factors
-Pressure (compression of tissue, to cut off blood supply)
-Shear force (pulling of the muscle &/or subcutaneous fat tissue away from the skin above, to cut off blood supply)
b/ Systemic factors
-Endothelial (blood vessel) damage (e.g. diabetes, smoking, artherosclerosis)
-Clotting tendencies

3. Aggravating Factors
a/ Metabolic disorders (genetic diseases that interfere with the assimilation & use of biological raw materials or components of food substances that are absorbed from
the guts & the elimination of by products mainly via the kidneys & lungs)
b/ Malnutrition (not enough raw materials taken in for repair)
c/ Moisture (high moisture predisposes)
d/ Temperature (high temperature predisposes)

Prevention (regular turning of the patient) is a very demanding job. In Papua New Guinea (PNG), there is a shortage of nursing staff and materials such as water beds etc. The usual surgical treatment is extensive surgical debridement without the proper use of a flap (chunk of nearby normal skin with intact blood supply) for coverage. This only worsens the condition, by extending the size of the wound.

Furthermore, the usual wound dressing method in PNG is hydrogen peroxide cleansing, followed by saline-gauze packing of the wound. The problems with this dressing method, are:

1. Destruction of normal granulation tissue (newly formed vessels) by the hydrogen peroxide
& the adherence of the gauze

2. Poor removal of exudates

3. No antisepsis

3. Painful during change of dressing

4. Bleeding during change of dressing

As a result, the wound healing process is very slow with a lot of complications. In PNG, the mortality rate (death from such cases) is very high.

In Goroka, we have introduced a new dressing method for pressure ulcers, trying as much as possible to avoid surgery. The steps are:

1. Use of absolute or 99.9% ethanol for wound cleansing & antisepsis, especially to treat bursas (tunnel under the skin)

2. Careful use of hydrogen peroxide to clean only the dirty portion of the ulcer without
disturbing the granulating areas

3. Hydrocolloid with antiseptic dressing until the wound is clean

4. When the wound is clean, only the hydrocolloid is used, until complete healing

Below is a photo of a patient who underwent such dressing method. This patient is diabetic and had osteomyelitis and developed septicemia, before commencement of the above wound dressing method. The patient recovered fully & was discharged home.

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