notes by dr. Claudio Italiano
We talk about pressure sores or "bedsores" or "pressure injury" when a tissue injury is determined in a patient, generally, bedridden, where the skin is compressed between the bone and the surface on which the body lies, subjected at a mechanical stress.
In these cases, the ischemia of the tissue resulting from this compression causes a tissue lesion, with necrotic evolution, which affects the skin, the dermis and the subcutaneous layers, until reaching, in very serious cases, the muscles and bones.
In this page you can see, for example, a conspicuous sacral decubitus plague, with a necrotic area that deepens up to the bone plane.
These are third-degree sores, but externally we can appreciate satellite injuries from second-degree decubitus.
The general factors favoring the formation of bedsores are:
Alterations of the state of consciousness (obfuscation of the sensory, coma,
etc.)
• Alterations of mental and behavioral abilities (dementia, apathy)
• Motor alterations and sensitivity (hemiplegia, paraplegia, neuropathies,
severe arthropathies, fractures and constructions in plaster or traction)
• Cardiac or respiratory diseases that cause a circulatory decompensation
• Excess of drug sedation
• Obesity or malnutrition
• General debilitating diseases (diabetes, renal failure, avitaminosis,
electrolyte imbalance, hypoprotinemia, etc.)
• Conditions of hypoxia
There are different types of sores classification: morphological, clinical and depending on color, appearance, exudate. In general, however, the most followed practical classification is the morphological classification in 4 stages, which are based on the severity of the lesions themselves, whether they are recent or inveterate, and on the degree of deepening in the tissues.
These are initial lesions with erythema of intact skin with limited edema. If at this first stage no action is taken, for example by changing the position of the patient, using an anti-bedsore mattress and taking care of the hygiene of the tissues and preventing their maceration, then from this stage the ulcer will pass, especially if skin pallor, heat or hardening appear.
This is characterized by a partial thickness lesion involving the epidermis and / or the dermis. The resulting ulcer is superficial and presents itself clinically as an abrasion (excoriation), a bladder or a slight cavity.
Full-thickness lesion involving damage or necrosis of the subcutaneous tissue with extension up to the muscle fascia. The ulcer is clinically presented as a deep cavity.
Full-thickness lesion with extensive destruction of the skin, tissue necrosis and muscle involvement, sometimes tendons and bones.
We talk about clinical classification because we believe that an ulcer has a
different healing depending on whether the patient is:
- patient in anabolic state, who eats, gets mobilized
- Patient in a catabolic state, which does not move, is cachectic, defiled,
terminal.
Therefore we distinguish three groups of patients (according to Nano - Strumia):
1nd GROUP They are huge necrotic plaques that are found in very serious and
debilitated patients and that can have a very rapid appearance with necrosis
that manifests itself in 36/48 hours.
Generally they consist of a single large lesion almost always sacral accompanied
by other small ulcers, all necrotic, in the various points of support.
2nd GROUP They are sores that are found in elderly patients in precarious
metabolic balance associated with intercurrent diseases (heart failure,
bronchial pneumonia), resulting from days of entrapment. These sores heal as
soon as the patient returns to being anabolic and is no longer enticed.
3th GROUP They are chronic lesions, in elderly patients, defected with different
intercurrent pathologies; therefore their treatment is difficult to solve. These
patients also have major metabolic problems that lead to a slow or impossible
granulation of sores.
The classification according to COLOR is useful both as an evaluation criterion
and for direct treatment.
Red: indicates the presence of clean and healthy granulation tissue. When the
lesion begins to heal, a pink layer is formed which then becomes flesh red.
Yellow: indicates presence of exudate that must be eliminated. It may be whitish
yellow, creamy yellow or yellowish green or beige.
Black: indicates the presence of d.escara. It slows the scarring and promotes
the proliferation of microorganisms.
One of the most important problems to take into account in the treatment of
bedsores is infections, which slow down all healing processes causing edema,
exudate also purulent resulting from cell destruction. Furthermore, the presence
of a "necrotic" black tissue prevents the repair of sores because it hinders
granulation and promotes infection. It is also true that in the attempt to "untangle"
the necrotic tissue from the sores, there is the risk of spreading the infection
further or of affixing to the lesion further bacteria, including the dangerous
multi-resistant pseudomonas aeruginosa! Hence eye in the curettage of the
lesions. Another problem is the increase of the local temperature and the
maceration of the tissues, especially in summer when the patient carries the
diaper and the urine and feces penetrate the lesion by infecting it and creating
an unhealthy "hot-humid" environment, causing further infection and heating of
lesions with increased metabolism and further increase of local tissue ischaemia.
It goes without saying that some factors intrinsic to the patient:
• Age
• Reduction of mobility
• Body structure
• chronic diseases
• Nutritional status
• Vascular insufficiency
• Immunosuppression
• Incontinence
These conditions are the basis for the perpetuation of pressure sores. The age
is responsible for the chronicity of the lesions because in the elderly the
metabolism is slowed down, the nutrition is deficient, the epidermis aged and
thinned and so is the local microcirculation.
The immunological response is reduced, the capacity of proliferation and slowed granulation of ulcers. In addition, the elderly person often experiences chronic conditions, for example in the conditions of fracture of the head of the femur, in the course of neurological diseases such as stroke cerebri, for pharmacological sedation during psychiatric illnesses and psychomotor agitation in subjects suffering from dementia (see fragile patient) and then because the subcutaneous tissue and the adipose panniculus is not very vascularized and therefore more vulnerable; the same applies to the thin patient, where the bony protuberances compress the thinened skin. Finally, the elderly is often affected by chronic disabling diseases such as diabetes, coronary heart disease, neoplasms, radiation treatments, chemotherapy, hypovitaminosis, cachectic states, anemic states, fever, the conditions of dysrotidemia (see microalbuminuria, albumin) , cirrhosis microalbuminuria heart failure incontinence of the sphincters)
It takes place and is carried out in 3 phases:
Inflammatory or defensive or reactive phase
Proliferative phase or fibroblastic phase
Ripening or remodeling phase.
It lasts from 4 to 6 days.
There are edema, pain, redness, increase in local temperature. Bleeding is
controlled by coagulation and platelet aggregation processes. Possible bacteria
are eliminated from polymorphonuclear granulocytes, while macrophages in
addition to eliminating bacteria cleanse the wound from cellular residues,
produce growth factors and transform macromolecules into amino acids and sugars.
It lasts from 4 to 24 days.
A bright red granulation tissue is produced in which macrophages, fibroblasts,
collagen, and newly formed blood vessels are present. The size of the wound
decreases due to the multiplication of the cells on its margins, until the two
edges come together ending the process of epithelialization and forming the scar.
It lasts from 21 days to 2 years.
There is a transformation of collagen fibers that ripen, reshape and acquire
considerable strength. The tension force that is reacquired can reach up to l.
80% of the original one.
Treatment of pressure sores
a) prevention is the first cure
b) place the anti-decubitus mattress
c) mobilize the patient every two hours
d) cleanse the care, change the diaper, avoid tissue maceration
e) intervene immediately when the injury is at the first degree.
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 widely used antiseptics are the iodic cadexomer, which exists in the
form of pasta or powder. The powdered form is mainly used in very exuding wounds,
the granules absorb the exudate releasing a 0.9% iodine dosage during the lesion,
performing a broad bactericidal effect without damaging the healthy cells, very
active against Gram + bacteria and Gram-, viruses, fungi, protozoa.
The product
does not develop bacterial resistance and does not exhibit high cellular cytotoxicity.
Treatment should be performed until complete regression of the infection and a
secondary absorbent dressing can be used as a polyurethane hydrocell foam. Still
the silver nanocrystal, with deposition of active silver, which blocks the
respiratory system of bacteria, gram + and gram -; Chlorhexidine acetate, a
bactericidal action that is used 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, cream version, gauze. 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.