Journal Club: Current Thoughts for The Prevention & Treatment of Pressure Ulcers

Sulaimaniyah Teaching Hospital

JOURNAL CLUBSupervised By: Dr. Sarmad Hiwa Arif

Prepared By: Meeran Earfan

Annals of SurgeryVol. 257, Number 4, April 2013

Review Article

Current Thoughts for the Prevention & Treatment

of Pressure UlcersUsing the Evidence to Determine Fact or Fiction

Steven M. Levine, MD, Sammy Sinno, MD, Jamie P. Levine, MD, and Pierre B. Saadeh, MD

IntroductionPressure ulcers are a significant cause of

morbidity.2-28% of nursing home residents experience

pressure ulcers.These wounds result from sustained pressure

against the skin & cause a local inflammatory reaction, potentially leading to bacterial contamination or systemic disease.

The severity varies according to the amount & quality of tissue involved.

Ulcer Grading Classification

Classification

Description

Grade I Erythema with intact skin

Grade II Skin erosion, blistering, partial loss of epidermis, and/or dermis

Grade III Loss of all skin layers & damage to subcutaneous tissue possibly down to fascia

Grade IV Damage to muscle, bone, or supportive structures (tendons or joints)

Risk Factors & AssociationsOne study showed that, incontinence,

smoking, hypoalbominemia, alcoholism, & diabetes were all associated with pressure ulcer formation.

Pressure & friction have both been shown experimentally to increase susceptibility to decubitus ulcer formation.

MethodsElectronic searches were performed using

the following databases: CENTRAL, Ovid MEDLINE (1950 to August 2011), Ovid EMBASE (1980 to August 2011), Ovid CINAHL (1982 to August 2011), & Google Scholar.

Many key words were then searched in each of the databases.

The search revealed several identified modalities for treatment &/or prevention of pressure ulcers. They then assessed each modality for the level of evidence that exists in the most current literature.

Levels of Evidence

Level of Evidence

Description

Level I Randomized controlled clinical trials, randomized systematic reviews

Level II Cohort studies, outcomes research

Level III Systematic review of case-control studies

Level IV Case series, case-control studies & reviews

Level V Expert opinions, experimental studies, animal- based research

Results:Modalities for Prevention & Treatment of

Pressure Sores

Wound Cleansers (Level II)By removing dead tissue & foreign bodies

from the wound, wound cleansers prepare the wound bed for dressing application.

Double-blinded randomized controlled trials have demonstrated the efficacy of Saline Spray containing aloe, Silver Chloride, & Decyl Glucoside in improving ulcer healing when compared with Saline alone.

Repositioning (Level V)Although repositioning is commonly used to

prevent pressure ulcer formation, to date, there are no randomized controlled trials that support this intervention.

Yet the evidence is insufficient to suggest optimal protocols for the frequency of positioning or optimal position for patients with pressure sores.

Nevertheless, repositioning is considered a practice with good face value, as added pressure to an area of vascular compromise will undoubtedly lead to a decrease in capillary blood flow.

Negative Pressure Therapy (Level I)Negative pressure devices are reducing

wound edema, decreasing the wound bioburden, & increasing local blood supply. However, the literature is inconclusive as to whether this therapy has an advantage for healing of pressure ulcers.

2 randomized controlled studies examined this for pressure ulcers. One showed a reduction in ulcer volume using vaccum- assisted wound closure, whereas another showed equivocal results when compared with traditional dressings.

Debridement (Level III, IV)Debridement options for pressure ulcers can include

biologic, autolytic, chemical, mechanical and enzymatic debridement.

Biologic: larvae or maggots.Autolytic: naturally occurring enzymes that dissolve

sloughed tissue.Chemical: sodium hypochlorite (Dakin’s).Mechanical: wet to dry dressing, wound cleansing, &

whirlpool debridement.Enzymatic: collagenase, papain, or urea.A recent Cochrane review demonstrated that there are no

randomized controlled trials to support any one methods of debridement over another.

Enteral & Parenteral Feeding (Level II, III)It is reasonable to conclude that nutritional

optimization has a beneficial effect on pressure sore healing.

A multicenter trial examining the effects of 2 daily oral supplemental drinks showed this intervention to significantly lower the incidence of pressure ulcers & identified low serum albumin levels & lower limb fracture as an independent risk factors.

A paired cohort study examined serum markers for metabolism in patients with spinal cord injury with pressure sores & noted that the surgical correction of sores resolved the serologic abnormalities such as in Hb & ptn.

Vitamins & Minerals (Level I)One double-blind randomized controlled trial of 88

patients with pressure sores showed a reduction in pressure sore area on application with 500mg of Vit.C twice daily for 4 weeks.

A multicenter study showed that application of 500mg of Vit.C twice daily for 12 weeks improved healing velocity.

A double-blind randomized controlled trialstudied the administration 200mg of Zinc sulfate 3 times daily for 24 weeks, this intervention failed to show any statistically significant effects in ulcer healing.

Specialized Mattresses (level I)A recent Cochrane review identified 52

randomized control trials & concluded that patients at high risk for developing pressure ulcers should have specialized mattresses as opposed to regular hospital mattresses.

Ultrasound Therapy (Level I)Ultrasound therapy has been proposed to

have a therapeutic effect on wound healing.The literature suggests, however, that

ultrasound therapy does not improve pressure sore healing.

No significant differences in healing were seen in 2 randomized controlled trials that compared ultrasound therapy with sham ultrasound therapy.

Another study failed to show statistically significant differences in healing between ultrasound/ultraviolet treatment & standard of care.

Honey (Level II)The mechanism of action of honey in wound

healing include antimicrobial activity, immunologic modulation, & physiologic mediation.

One trial randomly assigned patient with pressure ulcers to receive either honey or saline-soaked dressings. This study found that the overall time to healing in days was less in the honey-treated group.

Cellular Therapy(Level IV)Apligraf is an FDA-approved, living, bilayered

cell therapy that has been shown to be efficacious in a case study of patients with heel pressure ulcers.

In this study, 10 patients were treated with Apligraf & pressure offloading. The patients in this study had ulcers for an average of 161.3 days before using Apligraf & subsequently achieved a mean time to complete ulcer healing of 44 days with therapy.

Musculocutaneous & Fasciocutaneous Flap Closure (Level III, IV, V)

A study of 30 patients showed excellent reconstructive outcomes with tangentially split myocutaneous gluteus perforator flaps for pressure sores management without flap loss & few complications.

A recent review of the literature of all types of flaps performed for ischial pressure sores found an overall complication rate 0-80% & a recurrence rate from 0-33.3%. Unfortunately, given the uniqueness of each case including cause, age, & risk factors, it has been impossible to determine a hierarchy for flap selection.

Miscellaneous Modalities (Level IV, V)Sitting protocols postoperatively are of

unclear efficacy, as demonstrated in a study of hospice patients.

Ostectomy was shown in one small study to be an effective strategy to reduce the recurrence of pressure sores.

Authors ProtocolTransfer to a specialized air mattress.Optimization of nutrition, Vit. C 500mg twice daily.Turning protocol every 2 hours (Despite no high

level of evidence to support its use).Stage 1: Observation.Stage 2: Wound cleansers in the form of saline spray

that contains aloe, silver chloride, or decyl glucoside.Stage 3 & 4 almost always undergo sharp excisional

debridement, either at the bedside or in OT.They prefer using fasciocutaneous flaps in

ambulatory patients to minimize potential morbidity.

ConclusionsEvidence-Based Summery of the Effectiveness of Various

Modalities for the Prevention & Treatment of Pressure

Ulcers Treatment Modality Level of

EvidenceDemonstrated Effectiveness?

Wound Cleanser II Yes

Repositioning V Best practice guidelines

Negative Pressure Therapy

I No

Surgical Debridement III, IV Unclear which form of debridement is best

Enteral & Parenteral Feeding

II, III Yes

Vitamins & Minerals I Yes--- Ascorbic acidNo--- Zinc

Special Mattresses I Yes

Ultrasound Therapy I No

Honey II Yes

Flap closure III, IV, V Equivalence: depends on particular case