Pressure Sores In SCI Patients

1. Pressure Sores In SCI Patients A. Samer Alkawadri,M.D. Physiatrist Deputy Chairman, Department of PM&R Chief, Spinal Cord Injury Unit Ibenalnafees Hospital-Damascus

2. Difinition Pressure Sore ( P.S.) is a localized area of tissue necrosis that tends to developed when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time

3. Incidence&Prevalence in SCI Patients 33% had one or more P.S. of at least grade 1 severity. 14% had one or more stage 3 or 4 P.S. 8 % incidence in 1st year after Rehab. And 9% during 2nd year. Young(1981)found the incidence of new P.S. showed little difference between incomplete (20%)and complete(40%) lesions.

4. Cost Estimates put the cost at about 50,000 $ per hospitalization for treatment of a pressure Sore with an annual cost of more than 5 Billion $ nation wide

5. Cost Initial hospitalization (Young 1981) : - increased length of stay(LOS) : *1. No sores (mean LOS) : 4 months *2. No severe sores : 6 months *3. Severe pelvic sores : 8 months - wound care - surgical procedures

6. Cost Rehospitalization(Young 1981) P.S. are the number one reason for readmission to SCI centers Mean days hospitalized, year 2 : *1. No sores : 10 days *2. No severe sores : 26 days *3. Severe sores : 69 days Human/Societal costs : immeasurable

7. Risk factors Patients at risk (in general) : Decreased mobility Decreased sensation Altered mental state Incontinence Elderly

8. Risk factors Patients with Spinal Cord Injury : - Initial hospitalization (young 1981)

9. Further et al (1993) Presence of a sore : lower ASIA motor score Greater disability (lower FIM score) Severity of sore : race (black with more severe sores) Injury later in life Lower scores on occupation&mobility chart

10. Psychological&Social Factors(Richard 1981) Concept of physiological self-neglect P.S. correlated with age, number of persons living in the home, verbal intelligence P.S. correlated with psycho.measure tests : low ego strength, self-esteem, high degree of impulsive behavior without thought of consequences

11. Pathophysiology 1. Pressure : tissue vary in their sensibility to pressure(muscle is most sensitive,skin most resistive) Sores can develop from multiple causes : *low pressure over prolonged period of time *recurrent low pressure without adequate relief *high pressure for short periods of time

12. How much pressure is too much? Capillary pressure 32 mm Hg theoretically. Pressure measuring devices can be helpful The goal is even distribution of pressure on the seating surface, not merely relief of all pressure to < 32 mm Hg

13. Pathophysiology 2. Shear/Friction : Pressure level capable of distributing blood flow can be reduced by half in presence of significant shear forces

14. Pathophysiology 3. Tissue Temperature : Increased tissue temperature leads to increased blood flow, may lead to tissue necrosis 4. Moisture/Maceration : Reduces skin tolerance to mechanical stress

15. Pathophysiology 5. Metabolic/Nutrition : Protein : serum albumin correlates with P.S. stage. For each gram decrease in serum albumin, risk for P.S. increases 3 times P.S. improves with nutritional support Anemia(<10 mg/dl hemoglobin delays healing Smoking ( 75% of those with P.S. smoke ) Ascorbic Acid(necessary for hydroxylation of proline ): - several studies suggest that ascorbic acid is important in healing P.S.

16. Pathophysiology 6. Collagen : - there is up to five times slower wound healing below the level of SCI which may be due to decreased concentration of hydroxyproline, proline,hydroxylysine,lysine. there is a lower degree of hydroxylation of collagen specific amino acids which may lead to diminished tensile strength of skin after SCI Urinary excretion of collagen metabolites is increased in SCI persons possibly indicating an underlying defect of the collagen matrix or metabolism

17. Assessment/Classification 1. Stage : stage 1: Non-blanchable erythema of intact skin; the heralding lesions of skin ulceration

18. Stage Stage 2 : partial-thickness skin loss involving epidermis and/or dermis, the ulcer is superficial and presents clinically as an abrasion, blister, shallow crater

19. Stage Stage 3 : full-thickness skin loss involving damage or necrosis of subcutaneous tissue which extend down to, but not through,underlying fascia.the ulcer presents clinically as a deep crater with or without undermining of adjacent tissue

20. Stage Stage 4 : full-thickness skin loss with extensive destruction,tissue necrosis,or damage to muscle, bone,or supporting structures(tendon,joint,capsule�..)

21. Stage Stage 5 or Necrotic Ulcers with Eschar

22. Assessment/Classification 2. Location: gives clues to origin,allowing focused interventions Acute hospital: sacrum38%,heel19%,ischium16%,lower leg10% Acute SCI Rehabilitation : sacrum39%,heel 23%,ischium8% follow up (4 years after SCI) : sacrum 26%,ischium23% ,heel12% , trochanter10%

24. Assessment/Classification 3. Dimension : length x width x depth;presence of undermining or tracts

25. Assessment/Classification 4. Ulcer base : Color ( red, yellow, black ) Granulation tissue vs. chronic non granulating base Necrotic, fibrotic tissue Exudate

27. Necrotic

28. Sloughy

29. Infected

30. Granulating

31. Epithialising

32. Assessment/Classification 5. Surrounding tissue : ulcer edges, edema, redness, heat

33. Treatment/A Team Approach Non-Surgical Management

34. Non-Surgical Management Principle # 1: Prevention : nursing care(careful positioning,frequent turning,hygiene)

35. nursing care(careful positioning,frequent turning,hygiene)

36. Principle # 1: Prevention Passive protection: bed overlays,cushions (air, foam ,water, alternating air)

37. Principle # 1: Prevention Patient education (the most important factor in preventing P.S.;not always effective in changing behavior) Behavior modification (more research needed on effectiveness of these programs )

38. Non-Surgical Management Principle # 2:Correction of underlying factors: Pressure relief Equipment Anemia Nutrition Spasticity Contractures Psychological factors

39. Non-Surgical Management Principle # 3 :Adequate debridement and wound cleansing: Debridement : * sharp-fastest,most effective, but non-selective , painful * Mechanical-fast, non-selective, painful * Enzymatic-slower, selective, can use to wound healing

40. Non-Surgical Management Principle # 3 :Adequate debridement and wound cleansing: - wound cleansing: irrigation,wound cleansers * Irrigate with saline : Many commercial products available to aid in wound cleansing and not harmful to healthy granulation tissue Acetic acid, hydrogen peroxide, delute bleach solutions, povidone iodine. They may be useful for a short time in conjunction with appropriate debridement to control bacterial load but have detrimental effects on fibroblasts and wound healing Silver sulfidine has been shown to decrease the bacterial load in infected wounds without significantly impairing wound healing

41. Irrigation Instruments

42. Non-Surgical Management Principle # 4: Moist wound Healing : Gauze and saline �wet to moist� Properties and common uses of five major classes of wound care products . Transparent Membranes Hydrocolloids Foam Dressings Hydrogels Alginate Dressing

43. Transparent Membranes Properties -Semi-permeable -allows O2 exchange -prevents bacterial entry -promotes epithelial migration -prevents shear&friction Uses -stage 1,2 and shallow 3 -non-draining, clean, granulating wounds -autolytic debridement -secondary dressing -change when leaks or excess fluid

44. Transparent Membranes

45. Hydrocolloids Properties -occlusive barrier -forms gel with wound exudate -creates moist wound enviroment -prevents bacterial contamination - prevents shear&friction Uses -stage 1,2 and shallow 3 -minimal to moderate exudating wounds -autolytic debridement -secondary dressing -change when leaks

46. Hydrocolloids

47. Foam Dressings Properties -Semi-permeable, absorbtive, non-woven polyurethrane dressing -combines moist healing and absorbency -no dressing residue in wound -non-adherent to wound -thermal insulation -comfortable, trauma-free removal -can be used with topical Uses -stage 1,2 and shallow 3 -moderate to havily exudating wounds -donor sites -burns(1st & 2nd degree) -wound dehiscence -skin tears

48. Foam Dressing

49. Foam Dressing

50. Hydrogels Properties -water, polyethelene oxide or other compound -primary wound covering -moist wound enviroment -good for patient comfort -non-adherent to wound Uses -stage 2,3,4 -minimally exudating wounds -burns -autolysis-softens eschar -granulating or necrotic wounds

51. Hydrogel

52. Alginate Dressing Properties -hydrophilic, non-woven fiber -converts to gel -Ca and Na exchange -creates moist environment -non-adherent to wound Uses -stage 2,3,4 -moderate to havily exudating wounds -burns, vascular ulcers, graft sites -may be used with infected wounds

53. Alginate

54. Non-Surgical Management Adjunctive/Experimental Treatments: Growth Factors Hyperbaric Oxygen Electrical Stimulation Vacuum Assisted Closure

55. Surgical Management Procedures : split-thickness skin grafts Fascio-cutaneous flaps Myocutaneous flaps Free flaps Post-operative care : positioning and specially beds Drainage and antibiotics Time to resume sitting Sitting protocol

56. Post-Wound ManagementSecondary Prevention Patient re-education Equipment evaluation Recurrence: in a retrospective study of patients undergoing flap surgery, nearly 50% had recurrence of the ulcer within 1 year of healing

57. Complications Associated with P.S. Wound infection : -difficult to separate colonization from infection -bacterial counts of>100,000 will delay wound healing -diagnose with clinical exam -requires systemic antibiotics only if evidence of systemic infection or cellulitis -topical antimicrobials, such as silver sulfadiazine,may be helpful in reducing bacterial ,load

58. Complications Associated with P.S. Osteomyelitis : -definitive diagnosis only by biopsy-bone scan sensitive ,not specific-radiography not sensitive-clinical exam +/-, MRI may be useful -may require systemic antibiotic for 6 weeks

59. P.S. Prevention&Treatment Protocol Step 1 : Pressure Relief Stage 1:bed rest with regular bed only for ischial ulcer,no elevation of head,turned q2h Stage 2 :bed rest with air mattress,turned q2h Stage 3&4:bed with flexicare mattress, turned q4h

60. Step 2 :Local Wound Management Black Wound(eschar):mechanical sharp debridement till the wound becomes yellow

61. Step 2 :Local Wound Management Green&Yellow Wound(infected):enzymatic debridement, antibiotic ointment

62. Step 2 :Local Wound Management Red Wound (granulation tissue): Duoderm for small ulcer q3-5d, calcium alginate for drainage ulcer

63. Step 2 :Local Wound Management Wound with sinus cavity: irrigate cavity with n.s., irrigate with antibiotic solution(povidone)for infected wound

64. Step 3: Operative Treatment Operating room debridement: deep infected wounds Myocutaneous or Fasciocutaneuos Flaps: Stage 3 or 4 ulcers

65. Step 4 : Risk Factor Management Infection : antibiotic for cellulitis or soft tissue infection around the wound(cbc,esr,CT if osteomyelitits is suspected for stage 4 ulcer) Diabetes : keep blood sugar below 150mg/dl Nutritional deficiency :dietary consult to identify and correct risk factor albumen<3g/dl,weight loss, vitamin&mineral deficiency Spasticity :appropriate management Recurrent ulcers : psychology and social service consults for psychosocial problems

66. Step 5 :General Medical&Physical Management Physical therapy :Bedside exercise program Pulmonary Management : Chest PT

67. Step 6:Pre-discharge Assessment Physical Therapy :Transfer technique, wheelchair and wheelchair cushion FSA Evaluation :(Force Sense Assessment) seating pressure mapping,patient education Patient Education : pressure relief, tobacco, alcohol and obesity conselling, nutritional needs

68. Step 7:Post-discharge Management SCI-HC follow up : patients with recurrent ulcers, telemedicine for patients with improved but unhealed ulcers Flexicare Mattress : patients with recurrent ulcers, patient with insufficient family support