All of you will have happened, or we hope only a few, to have a patient who remains enticed for a long time, perhaps as a result of an operation for hip replacement or a fracture of the head of the inoperable femur, for which it was packaged a pinstriped knee-highs! At this point you will have noticed that there will be wounds in the sacral region, called "decubitus injuries". It is clear that the first treatment of a lesion of this type is to prevent it
To do this it is necessary that each structure has fresh, young, paid and
motivated staff in turn, but this happens only rarely! Most of the time, a
department, because of the continuous cuts to health, runs with little staff,
poorly paid, unmotivated and stressed, from continuous insults by the sick and
relatives, requests impossible to fulfill and so on! As far as possible, however,
we must obtain:
• A frequent change of position every two hours;
• An adequate body hygiene, not aggressive for the skin
• A diet adapted to health conditions, with protein preparations;
• Specific attention to existing diseases, ie to treat neurological, metabolic (diabetes)
and neoplastic diseases;
• One using specific aids and safeguards to prevent ulcers (anti-decubitus air
mattresses, advanced dressings, pillows;
• A good availability of staff that allows to raise as much as possible the
sick, to keep it at the table, to take it to the bathroom, to medicate it.
But what if I have to medicate at home?
In these cases it is always necessary a prescription issued by the specialist of
the ASL, or by the medical director of the operating units, of a public health
unit, which contains:
• Diagnosis (disabling pathology eg stroke, neoplasia, demyelinating disease,
etc.)
• Indication of the garrison and reference code (ISO Code), see below.
• Therapeutic program indicating the times of use
• The healthy company authorizes the supply on the basis of the prescription
At the discharge from the operative units, the patient affected by decubitus
injury must be accompanied by the prescription of bandages, in order to speed up
the procedures to access the medications, if this does not happen the practice
is very long, the attending physician must request a specialist visit to
domicile, when the doctor visits the patient at home will perform the
prescription of advanced medications.
The specialist doctor prescribes:
- flexible self-adhesive bandage with a surface of 10x10 or 20x20 or 60 cm or
120 cm.
- 50 gr hydrogel per month
on the request the months of treatment must be written according to the clinical
conditions of the lesion, the doctor can write 2, 3 or 4 months,
Other protections prescribed to the invalid patient affected by pressure
sores
• dynamic air mattress with compressor cod. iso 03.33.06.018
• protection for heel in siliconed hollow fiber cod. iso 03.33.09.006
• external catheter for men self-adhesive cod. iso 09.24.09.003
• envelope for external catheter cod. iso 09.27.07.006
• silicone permanent catheter cod. iso 09.24.03.003
Man has always tried to get the healing of sores, ulcers and wounds, using the strangest materials, from animal skins, eg. of fallow deer, to the impacts of mud and clay, to the leaves of cane, for ex. used decoctions of nepetella officinalis. While at the beginning of the twentieth century, the medicine believed that the healing of the lesions was possible in a dry environment, with dry bandages, e.g. gauze and linen, the real revolution was however in 1962, when Winter published his work on the lesions, healed in damp environment. In fact, dehydration of the tissues is responsible for cellular necrosis, since it is known that a humid environment is a vehicle of chemical mediators of the inflammatory response and that the cells of the organism move in an aqueous environment, resulting in a slow healing of the sores and of the cicatrization processes. An ideal dressing would have to be moist at the same time, to favor the drainage of exudates and not to pass the bacteria. Thus were born dressings such as hydrocolloids, polyurethanes, hydrogels.
The categories of products that today the Italian market allows us to have are:
- Hydrocolloids: Mixtures of natural or synthetic polymers suspended in a
microgranular form in an adhesive matrix.
- Alginates: Dressings based on calcium salts and / or sodium of alginic acid,
their degree of absorbance is high.
- Hydrogels: Fluid dressings based on hydrophilic polymers with a water content
of more than 50%; some may contain alginate. They are also available as a
support dressing.
- Polyurethanes: Polyurethane based dressings, permeable to water vapor and oxygen; on removal they leave no residue in the wound bed. The foams (simple, hydrocellular, hydropolymer) and those based on gelled polyurethane can be identified within this category.
Hyaluronic acid derivatives: Primary active
dressings in the form of multi-layered superabsorbent bearings for the gradual
release over time of polysynine solutions after having been previously activated
with them. A new type of advanced dressings, Active dressings: They are able to
reactivate the repair processes of damaged tissues, favoring the reconstruction
of tissues.
- Latest generation antiseptics: Based on nano silver crystals, or iodine
cadexomer, or argentine sulfadiazine and hyaluronic acid, are based on the slow
release of the active ingredient, absence of toxicity to tissue cells, very high
antibacterial activity towards many bacterial strains , mycetes, viruses, are
also able to reactivate tissue repair processes. Hyaff Hyaluronic Acid: Thanks
to its chemical and physical properties, hyaluronic acid is able to activate the
processes of tissue repair.
These injuries are serious and serious, the first thing to do is the inspection
of the lesion, that is, if it is characterized by necrotic tissue, by
inflammation, if it has subdued margins.
First, therefore, performed the inspection of the wound, we proceed to:
-
Removal of the necrotic tissue, that is of the eschar blackish, which is evident
at the surface of the wound, Wound Bed Preparation, ie preparation of the wound
bed;
-
Removal of the inevitable infectious and / or osteomyeltic processes; Who wrote
you came across hospital infections by killer bacterium, a century, pseudomonas
aeruginosa! And I do not tell you the wound pads made, that is the cultivation
tests of the purulent material that comes out of the wound and which is done by
dragging a sort of cotton stick on the secretion material, then insert it into
the special case and take it to the microbiological laboratory . If there is an
infection, the healing is very slow and stunted! It is not even said that the
use of more antibiotics can always be the right solution, because using only
disinfectants, the physiological solution for washing, iodine solutions, is
often sufficient, or even the old acetic acid, diluted!
When, finally, months pass and the patient, as in my case, is a patient with
spinal injuries and sores in the denervated regions, then the treatment is
difficult and also involves skin transplants, biological products or additional
therapies.
It is necessary to act on the lesion step by step: to favor the removal of the
necrotic tissues, regression of the bacterial colony, control of the exudates,
these are the first stages.
The composition of the exudate of chronic wounds, unlike that of acute lesions, is such as to slow down and block the proliferation of key cells such as keratinocytes, fibroblasts and endothelial cells. In particular, the hyperproduction of metalloproteinases determines the alteration of the reconstruction matrix, with degeneration of the components, such as proteins and growth factors, indispensable both for the migration of inflammatory cells and for re-epithelialization.
An assessment of the patient is fundamental, a careful medical history must be carried out, because many diseases of the body can cause diseases with altered tissue repair. For example those suffering from diabetic neuropathy, the heart patients and the neoplastic, those who have cycles of chemotherapy, who is weakened by anemia, malnutrition, malabsorption, with defective syndromes due to lack of vitamins, proteins, minerals, subjects suffering from rheumatoid arthritis or other autoimmune diseases. tissues.
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Calcaneal decubitus injury, in treatment with ligasan; it was necessary, however, to free the tissues from the necrotic parts to obtain the healing that always occurs by granulation from the margins of the lesions. Dressings were necessary for over 6-8 months. The first cure is the patience of the doctor and the patient. |
The injuries can present complications, of which the most dangerous are:
1. infections, colonization, contamination;
2. presence of necrotic tissue;
3. presence of fibrin
4. presence of abundant exudate;
5. subdivision;
6. extension of the lesion;
The scientific approach to wound treatment is based on the removal of local
barriers that hinder healing. The principles of TIME, which is based on
interventions in four important clinical areas, promotes the formation of a
well-vascularized lesion bed leading to healing, or the success of other
therapeutic measures.
To free the sores from the necrotic tissues it is possible to use enzymatic
preparations of collagenase and chloramphenicol, responsible for degradation of
the necrotic tissue. Specific hydrogels can also be used for this purpose:
-
Rehydrate the necrotic tissue
-
Dissolve and absorb serous necrosis
-
Absorb excess exudate
-
Promote the healing of wounds in a humid environment
It represents a dreadful complication of extensive sores, with inflammation sustained by the presence of pathogenic germs or, less commonly, by mycetes in a bone segment consisting of a cortical and a medullary space, close to the lesion, by simple diffusion of the infection to adjacent regions. If the bone segment is not provided with bone marrow, such as the calcaneus or a phalanx, the infection is called osteitis.
It is distinguished in acute and chronic. It is found that soft tissue infections (abscesses, phlegmons, bedsores, diabetic foot, and other chronic lesions) can be complicated by sepsis, a process in which a bacterial load can be found, through blood culture, a very serious pathology. of prognosis often unfortunate for the patient! The most used antiseptics are the iodine cadexomer, which exists in the form of paste or powder.The powdered form is used mainly in very exuding wounds, the granules absorb the exudate releasing in the wound a continuous dosage of iodine equal to 0.9% performing a broad bactericidal effect without damaging the healthy cells, very active against the Gram + and Gram- bacteria, viruses, fungi, protozoa The product does not develop bacterial resistance and does not present high cellular cytotoxicity.
Treatment should be carried out until the infection is regressed and a secondary absorbent dressing can be used as a hydr ocellular polyurethane. Still the silver nanocrystal, with deposition of active silver, which blocks the respiratory system of bacteria, gram + and gram -; Chlorhexidine acetate, with bactericidal action which is found as a dressing in the form of fat gauze, yet 1% silver sulfadiazine and hyaluronic acid 0.2% sodium salt, antiseptic with broad bacterial spectrum, in cream, gauze version. Excellent as an antiseptic, active against gram-gram +, the presence of hyaluronic acid ensures active tissue repair. The renewal of each dressing must take place at least every 3/4 days
Protein depletion, drugs like cortisone, anticoagulants, diseases such as anemia, circulatory deficiency, non-use of anti-bedsores, terminal diseases. The presence of non-proliferative margins should address the assessment of the general clinical condition of the patient, should be evaluated any treatment with substances such as protease modulators, autologous platelets, bioengineered dressings and local growth factors. In case the general clinical conditions of the patient are very compromised also the use of these products could be bankrupt. The use of broad-spectrum antibiotics in the local treatment of lesions is almost completely avoided and is replaced by the use of disinfectants with an increasingly high bactericidal activity and with reduced histology on the tissues. The removal of the necrotic tissue of the sores is, when possible, performed by enzymatic digestion rather than by surgery, as it is more physiological and less traumatic.
• dynamic air mattress with compressor cod. iso 03.33.06.018
• protection for heel in siliconed hollow fiber cod. iso 03.33.09.006
• external catheter for men self-adhesive cod. iso 09.24.09.003
• envelope for external catheter cod. iso 09.27.07.006
• silicone permanent catheter cod. iso 09.24.03.003