Review Decubitus ulcers: A review of the literature

1
ReviewDecubitus ulcers A review of the
literature

• Cheryl Bansal,BA, Ron Scott,MD, David Stewart,MD,
  and Clay J. Cockerell,MD
• International Journal of Dermatology 2005,44

2
Introduction and Pathogenesis

• Constant pressure can come from lying down
  (decubitus from the Latin decumbere, to lie
  down) or from sitting.
• Decubitus ulcers, also known as bedsores and
  pressure sores,are caused by impaired blood
  supply and tissue malnutrition owing to prolonged
  pressure over skin, soft tissue, muscle,and/or
  bone.
• Decubitus ulcers have probably existed since the
  dawn of humankind.
• They have been observed in unearthed human
  mummies and addressed in scientific writings of
  the19th century.

3
Introduction and Pathogenesis

• Decubitus ulcers can develop on any part of the
  body where sustained pressure and compressive
  forces are maintained for a sufficient period of
  time.
• sacrum and hips is most often affected (67),
• occiput, helices, elbows, and lower
  extremities (25), including heels and ankles.
• 25 of decubitus ulcers start in the operating
  room during surgery.
• 83 of hospitalized patients with decubitus
  ulcers developed them in the first 5 days of
  hospitalization.
• The prevalence rate in nursing homes is estimated
  to be 1728.

4
Introduction and Pathogenesis

• Impaired patients decubitus ulcers occur at an
  annual rate of 58, with lifetime risk estimated
  to be 2585.
• Decubitus ulcers are listed as the direct cause
  of death in 78 of paraplegics.
• Hospitalized patients have a 317 incidence
  rate, while hospitalized surgical patients have a
  1266 incidence rate.
• Immobilized patients in long-term care
  facilities have a 33 incidence rate.
• Some estimates suggest that 60,000 people die
  from decubitus ulcers or their sequelae per year.
• Present treatment costs for decubitus ulcers in
  the US is estimated in excess of 1 billion per
  year.

5
Morphology

• Several classification systems for decubitus
  ulcers have been described Daniels,Sheas,and
  the National Pressure Ulcer Advisory Panel
  (NPUAP), which is a modification of Sheas
  classification.
• The most widely accepted classification system
  for decubitus ulcers is the NPUAP.
• Stage I of the NPUAP classification represents
  intact
• skin with signs of impending ulceration
  blanching and/or nonblanching erythema, warmth,
  and induration.
• Stage II ulcers present clinically as a shallow
  ulcer (including epidermis and possibly dermis)
  with pigmentation changes.

6
Morphology

• Stage II ulcers, like Stage I, can be reversible.
• Stage III ulcer represents a full-thickness loss
  of skin with extension through subcutaneous
  tissue, but not underlying fascia.
• Stage IV represents full-thickness skin and
  subcutaneous tissue loss. resulting in
  involvement of muscle, bone, tendon, or joint
  capsule.

7
Histopathology

• Decubitus ulcers have many histologic stages.
• Clinically, the decubitus ulcer spectrum
  includes
• blanching erythema, nonblanching erythema,
• decubitus dermatitis, early ulcer, healing
  ulcer,
• chronic ulcer, and black eschar/gangrene.The
• progression is dynamic and multiple stages are
• often observed in one decubitus ulcer.

8
Treatment

• Today, the treatment of decubitus ulcers is based
  on four
• primary modalities (1) pressure reduction
  and prevention of additional ulcers, (2) wound
  management, (3) surgical intervention, and (4)
  nutrition.
• An additional way to reduce pressure involves
  turning and repositioning the patient every 2 h
  to reduce pressure on vulnerable areas.
• Current research indicates that the 2-h interval
  may not be adequate.
• The key aspects of wound management to ensure
  effective healing are cleaning and effective
  drainage and absorption while protecting the skin
  adjacent to the wound.

9
Treatment

• Skin adjacent to the wound may be lubricated to
  decrease friction and be kept relatively dry.
• Surgical intervention for decubitus ulcers
  involves debridement or flap creation for some
  Stage III and Stage IV ulcers.
• Malnutrition should be addressed because the
  malnourished patient has a higher susceptibility
  for ulcer formation.
• Other treatment modalities that can be employed
  as needed.

10
Treatment

• There are several risk assessment scales
  Norton,Cubbin and Jackson, Braden, Douglas,and
  Waterlow.
• Current studies show these risk assessment scales
  may not as effective as nurses judgement as to
  which atients are at risk.

11
Treatment

• Table 1 Decubitus ulcer Dos and Donts
• Dos
  Donts
• Move the patient or encourage the Do
  not use donut-type
• patient to move every 2 h
  cushions and device
• Keep skin clean and lubricated
  Keep skin dry
• Use pressure relief devices such as
• pillows, foam cushions, mattresses
• and gel heel protectors
• Pay special attention to skin areas with
• little fat padding, such as bony prominences
• Put patient on a stool and urine voiding
• schedule
• Use incontinence devices as appropriate
• Keep incline no higher than 30 degrees to
• prevent sliding and friction on lower back
• and buttocks

12
Outcomes

• Ferrell et al . found that no pressure ulcer
  healed completely or reduced in surface area
  greater than 50 within 30 days and only 14 of
  pressure ulcers completely healed within 79 days.
• This indicates that long-term therapy may be
  necessary.
• Yao-Chin et al . found 53 of pressure ulcers
  healed within 42 days.

13
Complications

• Osteomyelitis
• hypercalcemia
• myonecrosis
• necrotizing fasciitis
• amyloidosis
• sepsis
• gangrene
• death

14
Future Research

• Growth factors and hyaluronic acid have also been
  implicated in the process of wound healing.
• Becaplermin has been given FDA approval for
  treatment of lower extremity diabetic neuropathic
  ulcers. It may also have a place in the treatment
  of decubitus ulcers.
• Polyphenols such as catechin and black catechu
  have been found to have scavenger effects on
  oxygen radicals.
• Topical vitamin E has been found to accelerate
  the healing of skin wounds and ulcers.

15

• ????

16
(No Transcript)