Tag: Necrosis

Definition:
Over one million are afflicted with this life-threatening woundevery year, destroying tissue,fat, muscle, and infecting bone.
Caused by pressure on bony prominences that blocks flow of blood through capillaries

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A pressure-induced ulceration of the skin occurring in persons confined to bed for long periods of time. Also called decubitus ulcer, pressure sore.

Bedsores, more properly known as pressure ulcers or decubitus, are lesions caused by unrelieved pressure to any part of the body, especially portions over bony or cartilaginous areas. Although completely treatable if found early, without medical attention, bedsores can become life-threatening.

Bedsores, more accurately called pressure sores or pressure ulcers, are areas of damaged skin and tissue that develop when sustained pressure — usually from a bed or wheelchair — cuts off circulation to vulnerable parts of your body, especially the skin on your buttocks, hips and heels. Without adequate blood flow, the affected tissue dies.

Although people living with paralysis are especially at risk, anyone who is bedridden, uses a wheelchair or is unable to change positions without help can develop bedsores.

Bedsores can develop quickly, progress rapidly and are often difficult to heal. Yet health experts say many of these wounds don’t have to occur. Key preventive measures can maintain the skin’s integrity and encourage healing of bedsores.

Signs and symptoms:
The definitions of the four pressure ulcer stages are revised periodically by the National Pressure Ulcer Advisory Panel (NPUAP) in the United States. Briefly, however, they are as follows:

• Stage I. Initially, a pressure sore appears as a persistent area of red skin that may itch or hurt and feel warm and spongy or firm to the touch. In blacks, Hispanics and other people with darker skin, the mark may appear to have a blue or purple cast, or look flaky or ashen. Stage I wounds are superficial and go away shortly after the pressure is relieved.
• Stage II. At this point, some skin loss has already occurred — either in the epidermis, the outermost layer of skin, in the dermis, the skin’s deeper layer, or in both. The wound is now an open sore that looks like a blister or an abrasion, and the surrounding tissues may show red or purple discoloration. If treated promptly, stage II sores usually heal fairly quickly.
• Stage III. By the time a pressure ulcer reaches this stage, the damage has extended to the tissue below the skin, creating a deep, crater-like wound.
• Stage IV. In the most serious and advanced stage, a large-scale loss of skin occurs, along with damage to muscle, bone, and even supporting structures such as tendons and joints. Stage IV wounds are extremely difficult to heal and can lead to lethal infections.
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If you use a wheelchair, you’re most likely to dvelop a pressure sore on:

• Your tailbone or buttocks
• Your shoulder blades and spine
• The backs of your arms and legs where they rest against the chair

When you’re bed-bound, pressure sores can occur in any of these areas:

• The back or sides of your head
• The rims of your ears
• Your shoulders or shoulder blades
• Your hipbones, lower back or tailbone
• The backs or sides of your knees, heels, ankles and t

*Unstageable pressure ulcers are covered with dead cells, or eschar and wound exudate, so the depth cannot be determined.

With higher stages, healing time is prolonged. While about 75% of Stage II ulcers heal within eight weeks, only 62% of Stage IV pressure ulcers ever heal, and only 52% heal within one year. It is important to note that pressure ulcers do not regress in stage as they heal. A pressure ulcer that is becoming shallower with healing is described in terms of its original deepest depth (e.g., healing Stage II pressure ulcer).

Etiology:
Bedsores are accepted to be caused by three different tissue forces:

Pressure, or the compression of tissues. In most cases, this compression is caused by the force of bone against a surface, as when a patient remains in a single decubitus position for a lengthy period. After an extended amount of time with decreased tissue perfusion, ischemia occurs and can lead to tissue necrosis if left untreated in an immunocompromised patient.
Shear force, or a force created when the skin of a patient stays in one place as the deep fascia and skeletal muscle slide down with gravity. This can also cause the pinching off of blood vessels which may lead to ischemia and tissue necrosis.
Friction, or a force resisting the shearing of skin. This may cause excess shedding through layers of epidermis.
Aggravating the situation may be other conditions such as excess moisture from incontinence, perspiration or exudate. Over time, this excess moisture may cause the bonds between epithelial cells to weaken thus resulting in the maceration of the epidermis. Other factors in the development of bedsores include age, nutrition, vascular disease, diabetes mellitus, and smoking, amongst others.

There are currently two major theories about the development of pressure ulcers. The first and most accepted is the deep tissue injury theory which claims that the ulcers begin at the deepest level, around the bone, and move outward until they reach the epidermis. The second, less popular theory is the top-to-bottom model which says that skin first begins to deteriorate at the surface and then proceeds inward.

Causes:
Many people shift in their chair during meetings, fiddle with the radio when driving, turn a dozen times in their sleep. Every day, without thinking, they make hundreds of subtle postural adjustments that help stave off problems arising from inactivity. But for people immobilized by paralysis, injury or illness, those problems — including bedsores — are a constant threat.

Pressure sores usually result from sustained pressure on your body. They’re especially common in areas that aren’t well padded with muscle or fat and that lie just over a bone, such as your spine, tailbone (coccyx), shoulder blades, hips, heels and elbows. Because your skin and the underlying tissues are trapped between bone and a surface such as a wheelchair or bed, blood flow is restricted. This deprives tissue of oxygen and other nutrients, and irreversible damage and tissue death can occur.

In some cases, the pressure that cuts off circulation comes from unlikely sources: the rivets and thick seams in jeans, crumbs in your bed, wrinkled clothing or sheets, a chair whose tilt is slightly off — even perspiration, which can soften skin, making it more vulnerable to injury.

Other causes of pressure sores include:

• Friction. Frequent shifts in position are the key to preventing pressure sores. Yet the friction that occurs when you simply turn from side to side can damage your skin, making it more susceptible to pressure sores.
• Shear. This occurs when your skin moves in one direction, and the underlying bone moves in another. Sliding down in a bed or chair or raising the head of your bed more than 30 degrees is especially likely to cause shearing, which stretches and tears cell walls and tiny blood vessels. Especially affected are areas such as your tailbone where skin is already thin and fragile.

Pathophysiology:
Pressure ulcers may be caused by inadequate blood supply and resulting reperfusion injury when blood re-enters tissue. A simple example of a mild pressure sore may be experienced by healthy individuals while sitting in the same position for extended periods of time: the dull ache experienced is indicative of impeded blood flow to affected areas. Within hours, this shortage of blood supply, called ischemia, may lead to tissue damage and cell death. The sore will initially start as a red, painful area, which eventually turns purple. Left untreated, the skin may break open and become infected. Moist skin is more sensitive to tissue ischemia and necrosis and is also more likely to get infected.

Epidemiology
Within acute care, the incidence of bedsores is 0.4% to 38%; within long-term care, 2.2% to 23.9%; and in home care, 0% to 17%. There is the same wide variation in prevalence: 10% to 18% in acute care, 2.3% to 28% in long-term care, and 0% to 29% in home care. There is a much higher rate of bedsores in intensive care units because of immunocompromised individuals, with 8% to 40% of ICU patients developing bedsores.

The risk of developing bedsores can be determined by using the Braden Scale for Predicting Pressure Ulcer Risk. This scale is divided into six risk categories:

sensory perception
moisture
activity
mobility
nutrition
friction and shear
The best possible interpretation is a score of 23 whilst the worst is a 6. If the total score is below 11, the patient is at risk for developing bedsores.

Screening and diagnosis:
Bedsores are usually unmistakable, even in the initial stages, but your doctor is likely to order blood tests to check your nutritional status and overall health. Depending on the circumstances, you may have other tests, including:

• Urine analysis and culture. A sample of your urine may be examined for various reasons, but you’re especially likely to have this test if you have a problem with incontinence. The test also checks for kidney problems and urinary tract infections, which may be a particular concern for people with spinal cord injuries.
• Stool culture. In cases of fecal incontinence, a sample of your stool may be sent to a laboratory for analysis.
• Biopsy. When you have a wound that doesn’t improve, even with intensive treatment, or you have chronic pressure sores, your doctor may remove a small sample of tissue that allows for a complete bacterial evaluation. The tissue may also be checked for cancer, which is a risk in people with long-standing wounds.

Treatment:
The most important thing to keep in mind about the treatment of bedsores is that the most optimal outcomes find their roots in a multidisciplinary approach; by using a team of specialists, there is a better chance that all bases will be covered in treatment.

There are six major contributors to healing.:-

Debridement:
The removal of necrotic tissue is an absolute must in the treatment of pressure sores. Because dead tissue is an ideal area for bacteria growth, it has the ability to greatly compromise wound healing. There are at least seven ways to excise necrotic tissue.

Autolytic debridement is the use of moist dressings to promote autolysis with the body’s own enzymes. It is a slow process, but mostly painless.
Biological debridement, or maggot debridement therapy, is the use of medical maggots to feed on necrotic tissue and therefore clean the wound of excess bacteria. Although this fell out of favour for many years, in January 2004, the FDA approved maggots as a live medical device.
Chemical debridement, or enzymatic debridement, is the use of prescribed enzymes that promote the removal of necrotic tissue.
Mechanical debridement is the use of outside force to remove dead tissue. A quite painful method, this involves the packing of a wound with wet dressings that are allowed to dry and then are removed. This is also unpopular because it has the ability to remove healthy tissue in addition to dead tissue. Lastly, with Stage IV ulcers, there is the chance that overdrying of the dressings can lead to bone fractures and ligament snaps.
Sharp debridement is the removal of necrotic tissue with a scalpel or similar instrument.
Surgical debridement is the most popular method, as it allows a surgeon to quickly remove dead tissue with little pain to the patient.
Ultrasound-assisted wound therapy is the use of ultrasound waves to separate necrotic and healthy tissue.

Infection control:
Infection has one of the greatest effects on the healing of a wound. Purulent discharge provides a breeding ground for excess bacteria, a problem especially in the immunocompromised patient. Symptoms of systemic infection include fever, pain, erythema, oedema, and warmth of the area, not to mention purulent discharge. Additionally, infected wounds may have a gangrenous smell, be discoloured, and may eventually exude even more pus.

In order to eliminate this bioburden, it is imperative to apply antiseptics and antimicrobials at once. It is not recommended to use hydrogen peroxide for this task as it is difficult to balance the toxicity of the wound with this. New dressings have been developed that have cadexomer iodine and silver in them, and they are used to treat bad infections. Duoderm can be used on smaller wounds to both provide comfort and protect them from outside air and infections.

It is not recommended to use systemic antibiotics to treat infection of a bedsore, as it can lead to bacterial resistance.

Nutritional support:
Upon admission, the patient should have a consultation with a dietitian to determine the best diet to support healing, as a malnourished person does not have the ability to synthesize enough protein to repair tissue. The dietitian should conduct a nutritional assessment that includes a battery of questions and a physical examination. If malnourishment is suspected, lab tests should be run to check serum albumin and lymphocyte counts. Additionally, a bioelectric impedance analysis should be considered.

If the patient is found to be at risk for malnutrition, it is imperative to begin nutritional intervention with dietary supplements and nutrients including, but not limited to, arginine, glutamine, vitamin A, vitamin B complex, vitamin E, vitamin C, magnesium, manganese, selenium and zinc. It is very important that intake of these vitamins and minerals be overseen by a physician, as many of them can be detrimental in incorrect dosages.

How to properly care for a bedsore:
The most important care for a patient with bedsores is the relief of pressure. Once a bedsore is found, pressure should immediately be lifted from the area and the patient turned at least every two hours to avoid aggravating the wound. Nursing homes and hospitals usually set programs to avoid the development of bedsores in bedridden patients such as using a standing frame to reduce pressure and ensuring dry sheets by using catheters or impermeable dressings. For individuals with paralysis, pressure shifting on a regular basis and using a cushion featuring pressure relief components can help prevent pressure wounds.

Pressure-distributive mattresses are used to reduce high values of pressure on prominent or bony areas of the body. However, methods to evaluate the efficacy of these products have only been developed in recent years.

Educating the caregiver
In the case that the patient will be returning to home care, it is very important to educate the family about how to treat their loved one’s pressure ulcers. The cross-specialisation wound team should train the caregiver in the proper way to turn the patient, how to properly dress the wound, how to properly nourish the patient, and how to deal with crisis, among other things.

As this is a very difficult undertaking, the caregiver may feel overburdened and depressed, so it may be best to bring in a psychological consult.

Wound intervention:
Once the patient has reached the point that intervention is possible, there are many different options. For patients with Stages I and II ulcers, the wound care team should use guidelines established by the American Medical Directors Association (AMDA) for the treatment of these low-grade sores.

For those with Stage III or IV ulcers, most interventions will likely include surgery such as a tissue flap, skin graft or other closure methods. A more recent intervention is Negative Pressure Wound Therapy, which is the application of topical negative pressure to the wound. This technique, developed by scientists at Wake Forest University, uses foam placed into the wound cavity which is then covered in a film which creates an airtight seal. Once this seal is established, the technician is able to remove exudate and other infectious materials in addition to aiding the body produce granulation tissue, the best bed for the creation of new skin.

There are, unfortunately, contraindications to the use of negative pressure therapy. Most deal with the unprepared patient, one who has not gone through the previous steps toward recovery, but there are also wound characteristics that bar a patient from participating: a wound with inadequate circulation, a raw debridled wound, a wound with necrotised tissue and eschar, and a fibrotic wound.

After Negative Pressure Wound Therapy, the patient should be reevaluated every two weeks to determine future therapy.

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Complications:
Pressure sores can trigger other ailments, and cause patients considerable suffering and financial cost. Some complications include autonomic dysreflexia, bladder distension, osteomyelitis, pyarthroses, sepsis, amyloidosis, anemia, urethral fistula, gangrene and very rarely malignant transformation. Sores often recur because patients do not follow recommended treatment or develop seromas, hematomas, infections, or dehiscence. Paralytic patients are the most likely people to have pressure sores recur. In some cases, complications from pressure sores can be life-threatening. The most common causes of fatality stem from renal failure and amyloidosis.

Risk Factors:
If you’re immobilized by acute illness, injury or sedation — even for a brief time such as after an operation or accident — you can develop pressure sores. But people living with spinal cord injuries are at greatest risk.

Because the nerve damage from these injuries is often permanent, compression of skin and other tissues is ongoing. Exacerbating the problem are thinning or atrophied skin and decreased circulation, both of which make tissue damage more likely and healing more difficult. And because spinal cord injuries reduce or eliminate sensation, you don’t receive the body signals that tell you to shift your position or that a sore is developing.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose

Resources:
www.mayoclinic.com
http://en.wikipedia.org/wiki/Bed_sore

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