decubitus ulcers: prevention and managmentoct 11, 2017 · • 1993: 281,3000 admissions for...
TRANSCRIPT
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Decubitus Ulcers: Prevention and Managment
Joseph H. Shin MD Professor of Clinical Surgery
Chief of Plastic Surgery Montefiore Medical Center
Albert Einstein College of Medicine
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Disclosure
• Clinical Trial Investigator: Smith and Nephew
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Plastic Surgery: Dr. 90210 • Dr. 90210
• Extreme Makeover
• Miami Slice
• Nip/ Tuck
• Reality TV?
• Fiction?
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Plastic Surgery
• Craniofacial Surgery • Hand Surgery • Cleft Lip and Palate • Burn Surgery • Trunk/Lower Extremity
Surgery • Trauma Reconstruction • Tumours/ Reconstruction • Aesthetic Surgery
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Aesthetic Surgery Breast Augmentation:
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Cleft Lip and Palate
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Bilateral Cleft Lip
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Case 1:
• 18 mo boy
• Total nasal amputation
• Dogbite
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Preop:
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Microsurgery HBO2 > Flap Failure (18mos)
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Postop 9 mos (3yo)
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Wound Healing
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Pressure / Decubitus Ulcer
• “ a localized injury to the skin /and or
underlying tissue usually as a result of pressure
or pressure in combination with shear”
(NPUAP/ EPUAP Joint Statement 2007)
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Pressure Ulcer: Sacrum
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Pressure Ulcer • 2.5 million pressure ulcers treated in US annually
• Cost of care: $11 Billion Dollars annually (CMMS)
• 1993: 281,3000 admissions for pressure ulcers
• 2006: 503,300 admission for pressure ulcers
– 79% increase (HCUP)
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Predisposing and risk factors
• Age: elderly =60% of all patients with pressure ulcers
• Neurologic/sensory disorders
• Immobility
• Malnutrition
• Mental Illness/Dementia
• Dehydration
• Diabetes
• Incontinence
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Pressure Ulcers
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Prominence /Proximity to Bone
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Sacrum/ Ischium
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Prevention/ Diagnosis
• Pressure Mapping
• Wheelchair Testing
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PRESSURE MAPPING
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Identification of specific points of pressure
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Prevention: Identification of Risk • BRADEN SCALE
• WATERLOW SCALE
• NORTON SCALE
• VARIABLES:
– MOBILITY/MENTAL STATUS. BMI.
NUTRITION. CONTINENCE
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Prevention: Repositioning
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Prevention: Surface
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Prevention: Support
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Prevention
• Support Surface:
– Cushion
– Mattress
– Bed system
– Low pressure
– Alternating Pressure
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BED SURFACES AIR FLUIDIZED A feature of a support surface that provides pressure redistribution via a fluid-like medium created by forcing air through beads as characterized by immersion and envelopment. ALTERNATING PRESSURE A feature of a support surface that provides pressure redistribution via cyclic changes in loading and unloading as characterized by frequency, duration, amplitude, and rate of change parameters. LATERAL ROTATION A feature of a support surface that provides rotation about a longitudinal axis as characterized by degree of patient turn, duration, and frequency. Low Air Loss A feature of a support surface that provides a flow of air to assist in managing the heat and humidity (microclimate) of the skin.
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Management
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Management • Risk Reduction
• Nutrition
• Additional Off-Loading
• Cleansing
• Padding
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Management: Debridement
• Tissue Necrosis
• Bacterial Overload (Infection)
• Moisture Imbalance
• Impairment of Healing Edge (Undermining)
• (TIME)
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Management: Debridement Sharp Surgical Debridement
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Management: Debridement • Hydrosurgery
• Biologic:
– Enzymatic
• Mechanical
– Dressing
– Negative Pressure
– Autolytic
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Compromised Wound Healing
TMP’s
Edema
Pathogen
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Reconstructive Surgery
• Negative Pressure
Therapy: Vacuum
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Mechanisms of Action
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Bacterial Clearance Mean of Log Organisms/Gram Tissue
(n=5)
0123456789
10
Day 0 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
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Blood Flow Data
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Reconstructive Surgery
• Reconstructive Ladder
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Management : Surgery
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Sacral Ulcer
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Debridement/ Wound Vac
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Sacral Ulcer
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Gluteus Muscle Flap
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Negative Pressure Dressing
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Reconstructive Surgery
• 50 yr old Fireman
• Grafts?
• Flaps : Local And
Regional?
• Free Tissue Transfer?
• Amputation??
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Reconstructive Surgery
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Reconstructive Surgery
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Pressure Ulcer Heel
• Ambulating
• Heel Breakdown
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Sural Island Flap • Jeng SF. Wei FC.
Distally based sural
island flap for foot and
ankle reconstruction.
Plastic &
Reconstructive
Surgery. 99(3):744-50,
1997 Mar
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Reconstructive Surgery
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Reconstructive Surgery
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Reconstructive Surgery
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Reconstructive Surgery:
• 3 yr F/U: ambulating
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Late Sequelae: Marjolin’s Ulcer: SCC
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Fasciocutaneous Flap
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• Control of Spasms
• Diversion of Urine/ Bowel Diversion
• Meticulous Postoperative Control of Pressure
• Nursing Care
• Recurrence = 3-80% approximately (depending upon location)
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New Technology
• Negative Pressure Wound Therapy/ Closed
Incisions
• Pressure Sensors
• Sensory Nerve Transfers
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Pressure Sensors
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Summary • Pressure Ulcers: Incidence increasing
• Preventable
• Cost : Increasing Dramatically
• Litigation: Failure to prevent
– (CMMS/Plaintiff Bar) 87% loss rate
• Increasing role of surgeons in management
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Thank you!