Pressure Sores
Pressure sores occur in soft tissues on bone protrusions exposed to pressure in the body. In the past, these wounds were described as decubitis ulcers. Decubitis is a Latin word which means lying on your back. Since the wound is opened in the ischial areas in people sitting, it is more accurate to use the definition of pressure sores instead of decubitis.
85-90% of pressure sores are commonly seen in the sacral, trochanter and ischial regions of the lower waist. It occurs less commonly in the heel malleols, pretibial region, elbows, scapula, occipital regions. In developed countries, people with medulla spinalis injury survive in a wheelchair, and these are more commonly associated with pressure sores in the ischial regions. In our country, sacral and trochanter pressure sores are seen more frequently since most of these patients are left to bed.
Pressure sores are most commonly seen in patients with medulla spinalis damage, deprived of skin sensitivity, and in elderly and uncared patients who remain bed-dependent for chronic illnesses. Pressure is an important factor in the etiology of pressure sores. The duration of pressure in wound formation is more effective than pressure intensity. If the pressure affecting the soft tissue on the bone protrusions exceeds the capillary pressure in this region (above 35 mm Hg) and continues for a long time, changes starting at the cellular level will cause damage to the tissue necrosis.
If the pressure is removed in a short time, necrobiotic changes return with regional inflammatory response. If the pressure persists for a long time, the capillary circulation will deteriorate. As a result, anoxia develops in soft tissues and thrombosis occurs in small vessels. Obstruction of venous and lymphatic microcirculation causes accumulation of metabolic products and accelerates tissue necrosis. Addition of secondary infection affects the wound negatively.
Tensile forces are also an important factor in the formation of pressure sores. Raising the head of the bed more than 30 degrees creates tension in the lower parts of the body. Pressure and tension accelerate wound formation. In addition, regional friction, bruise, maceration, uncontrolled spasticity, anemia, hypoproteinemia, vitamin deficiencies, alcoholism, drug dependence, diabetes, peripheral vascular diseases, cancer, poorly wound dressings and splints are other important factors in the formation of pressure sores.
CLASSIFICATION OF PRESSURE WOUNDS
Although different classifications are used in pressure sores, there are 5 stages according to the most commonly used classification.
Stage 1: Skin erythema, edema and induration. If the pressure is removed and well maintained, the event is reversible and recovery is complete.
Stage 2: There is advanced superficial necrosis into the dermis. Conservative treatment improves.
Stage 3: Complete necrosis of the skin The lesion descends into the subcutaneous tissue. If secondary infection is added, the wound becomes complicated. Surgical intervention is required for large lesions.
Stage 4: The lesion includes bone tissue and the bone descends to the protrusion. Treatment is surgery.
Stage 5: The lesion has spread to bone tissue, joints and body cavities. Osteomyelitis, pathological fractures, dislocation of joints, internal organs fistulas, septicemia may develop. According to the spread of the lesion is often serious cases. Surgical intervention is required.
This classification may not always be clinically observed. Most of the time, the defect in the compression wound is cone-shaped. The top of the cone is in the skin and the base is between deep tissues.
Occasionally, a small and lesion of the skin may present with pressure sores of stage 4 and 5.
PREVENTION OF PRESSURE WOUNDS
Measures to be taken to prevent pressure sores are easier and more economical than their treatment.
The first step in the prevention of pressure sores is education. Patients and their families and hospital staff should be educated about the causes and consequences of wounding. The most effective method to prevent these wounds is to change position frequently. Often, these patients should change positions every 2-3 hours.
People in wheelchairs should raise themselves with their hands every 2-3 hours and ensure that these areas are blooded.
Skin and bed care is very important. The skin is wiped with soapy water every day and dried carefully. Massage is applied in order to increase circulation, durability of the skin. Bed linen should be clean and dry. The bed and linen under the patient should not be wrinkled.
Urine and cleaning after defecation is very important in bedridden.
Anemia, hypoproteinemia, vitamin deficiencies, improper dressings and splints, which may cause pressure sores to open, should be eliminated.
Spasticity should be tackled. Although many beds, wheelchairs and cushions have been developed to prevent wound formation, no equipment has been produced to prevent all of the pressure sores.
TREATMENT
Conservative Treatment: If pressure sores are opened, necessary precautions should be taken before they become complicated. In stages 1 and 2, the pressure is removed, and a good maintenance is achieved. If the pressure continues, the wound deepens and becomes complicated.
Many topical agents are used in wound care. Although there has been much progress in wound care in recent years, topical agents are being used in many places that can delay wound healing and damage tissues. The most ideal solution for wound cleaning is lactated ringer and saline which are closest to tissue osmolarity. Betadine solution is the least damaging to the cells and can be used in flowing effect wounds.
Although topically used antibiotics are still controversial, resistant bacteria may develop in a short time and are not economical. Antibiotics given systemically cannot reach the wound sites due to the barrier formed in these wounds. Systemic antibiotics should be given against secondary infections.
Although flora changes frequently in these wounds, wound culture should be performed for nosocomial infection.
Many synthetic and semi-synthetic materials have been developed in wound care in recent years. Most of these are not both economic and misused. These substances should be used as temporary skin dressing only if the wound is clean and there is no necrosis in cases that may delay surgery for various reasons. Some of them prevent the loss of fluid, electrolyte and protein from the body.
Various agents are available to accelerate wound healing. Hydrotherapy, hyperbaric oxygen, ultrasound, electric currents, some topically used pomades are useful in superficial wounds where skin supplements are not lost.
After removal of necrotic tissue in deep wounds where skin appendages disappear, all wounds can be closed by epithelialization from the edges with good topical care. The scar tissue, however, lacks skin patches. It may cause continuous pressure sores. Large scars that heal with scar tissue may develop malignant skin tumors in later stages.
Surgical Treatment: 3.4. In the 5th and 5th stages, surgical method is used to treat pressure sores. If the patient's blood values are low in the preoperative period, it should be brought back to normal values that may be operated.
In order to be successful in the treatment of pressure sores, necrotic tissue should be removed as soon as possible. Although enzymatic debridement methods are used for this, surgical debridement and defect repair should be preferred. The aim of the treatment is to bring pressure-resistant tissues with good blood to the wound area. Since the muscle-skin and fascia-skin flaps used in repair are well-blooded, they provide superiority to other repair methods in the fight against infection at the wound site. In surgical repair, bone protrusions are excised together with the period to prevent recurrences following debridement. 3. Primary suture, free skin grafts, muscle, muscle-skin and faysa-skin flaps are used for surgical repair of pressure sores of stage 4 and 5. The recurrence rate of compression wounds treated with free skin graft and primary repair was 40%, while the recurrence rate in muscle-skin flaps decreased to 5%. Therefore, muscle-skin and fascia-skin flaps should be preferred for defect repair.
The choice of flaps in surgical repair should be considered in the future pressure sores of the patient. Glucus maximus fascia-skin flap, tensor faysa-lata flap in the trochanter region and biceps femoris muscle-skin flap in the ischeal region are used as the first choice in the repair of the sacral compression wound.
In patients who do not have medullasipinalis injury, muscle and muscle-skin flaps should not be used in compression wound repair, as muscle-related functional losses will occur.
Postoperative care:
Postoperative care of patients with pressure sores is very important. Patients with flap are usually not laid on the flap for 3 weeks. In this period, starting from the first week, the patient can be given passive movements to the joints according to the surgical characteristics. Prevention of cypasticity after surgery is very important for wound removal. Vacuum drains 5-7. days, the patient is dressed in an elastic corset. Sutures are removed after 10 days. If there is no complication in flap cases, after 3 weeks, patients may begin to lie on the flap. This process starts with 15 minutes per day and can be increased every 5 to 5 minutes. This period should never exceed 2 hours.
Mean duration of hospitalization in patients with pressure injuries is 5-6 weeks. When the surgical costs are considered, it is seen that the precautions to be taken to prevent these wounds are easier and more economical.
18AXX
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