Pressure Sores

Question 1

What are RFs for the development of pressure sore

Answer 1

Extrinsic

• shear forces
• friction
• pressure

Intrinsic factors (2Is, 4Ms, 3A, 2S

• Infection
• Ischemia
• Moisture
  
  • incontinence
• Malnutrition
  
  • hypoproteinemia
• Mobility
• Mental status
• Autonomic control
• Anemia
• Age
• Sensory loss
• Small vessel disease

Question 2

How do you manage pressure sores?

Answer 2

HISTORY

• General Hx: Mobility, functional capacity
• Factors relating to wound healing: DM/CVD/PVD/ESRD, smoking, steroids, immunosuppression, radiation
• Wound history: onset, duration, changes, pain, sensation, prevous investigations nad wound care managemeent

PHYSICAL EXAM

• Wound location
• Wound: size, depth, edema/infection, base of wound tissue necrotic/slough/granulation, NV status
• Condition of surrounding tissue/previous scars

INVESTIGATions

• CBC, lyes, Cr, urea, Alb, preAlb, ESR CRP, HbA1C/glc
• If concerned for osteomyelitis, MRI (r/o OM most sp/sen) +/- Bone biopsy

PREVENTION

• Education
• Skin care - pH based solution
• Pressure Relief
• Medical optimization
  
  • correct spasticity (bacrofen, diazepam, dantrolene
  • optimize systemic D (HTN, DM)
• Smoking cessation
• manage incontinence
• optimize nutrition :
  
  • need albumin >2mg/dL for wound healing
  • 1.5-3mg/kg/day protein and 25-35kcal/kg/day non-protein
  • vit a,c, Zn, Cu, Fe, Ca

Question 3

What are treatment options for pressore sore?

Answer 3

Non-operative

• local wound care
  
  • debridement of necrotic tissue
  • treat infection
    
    • IV abx for OM, topical antimicrobial, oral/iv based on culture
• dressing to prevent future infection and promote helaing
  
  • eschar =>hydrogel and trasnparent film
  • grnaulating =>hydrocolloid
  • slough =>lots of exudate =>alginate
  • slough => minimal/no exudate =>hydrocolloid
  • slough moderate exudatehydogel and absorbant film
• NPWT

Operative

• excision of ulcer, scar, underlying bursa (using methylene blue), ST calcifications
• ST and bone biopsies for targeted abx
• Remove bony prominences (or ensure padding)
• Obliterate dead space
• resurface with flap

Question 4

What are contraindications to NPWT

Answer 4

• necrotic tissue
• untreated osteomyelitis
• malingnant tissue
• non-enteric or unknown/not explored fistula
• presence of fistula into cavity near wound
• allerg to NPWT materail

Question 5

What are indications for NPWT

Answer 5

• stage 3 4 pressure sore
• wound base large enough for sponge to contact wound bed
• tunneling/undermining
• edema
• poor grannulation tissue

Question 6

What are 3 mechanisms of action of NPWT

Answer 6

• wound contraction via recruitment of fibroblast
• removal local inflmmatory mediators
• removal of edema - improved 02 delivery

Question 7

How do you decide your management plan for treatmetn options?

Answer 7

Based on stage of wound

• Stage 1/2 - conservative management
• Stage 3/4 - consider operative managmeent if good candidate
  
  • nutrition optimized? alb>2, protein 1.5-3mg/kg/dm hBA1c<6
  • spasm contolled?
  • infection/OM owrkup?
  • postop plan of care?
• If not meeting above, optimize then reconsider

Question 8

What is the post-op management plan

Answer 8

• no pressure on recon for at elast 2-3wks
• protect other areas form developign pressure sore
• Abx dictated by Cx
• continue medical optimization

Question 9

Whata re reconstructive options for presure sore

Answer 9

• stsg
• tissue expansion
• local/regional flap
• free flap

Answer 10

What are pro/con to MC/muscle flap vs fasciocutaneous flap for pressore sore recon?

• Muscle/MC flaps
  
  • Pro - fill dead space, well vascularized, able to cover large areas
  • con - susceptible to ischemi w [ressure, atrophy of muscle w disuse, donor site morbidity
• FC flaps
  
  • Pro - tolerant of pressure ischemia, less donor morbidity
  • Con - less volume for dead space

Question 11

What are options for Sacral recon

Answer 11

• Gluteal FC/MC rotation flap
• Gluteal V-Y advancement FC/MC flap
• Gluteus maximus flap
• Lumbosacral flap

Question 12

What are options for ischial reconstruction?

Answer 12

• medial/posterior thigh flap
• gluteus maximus flap
• hamstring V-Yadv (biceps femoris)
• gracilis MC flap
• Extended TFL

Question 13

What are options for Trochanteric recon?

Answer 13

• TFL
• pedicled ALT
• VL
• Recus femoris
• Gluteal/posterior thigh

Question 14

What are components of braden scale?

Answer 14

Moisture

Activity

mobility

nutrition

friction/shear

Sensory perception