Part 2

Last week we promised you that we would continue the topic of decubitus ulcers or so-called bedsores. After through the eyes and experience of Assoc. Prof. Dr. Yordanov, consultant in anesthesiology and resuscitation, pain treatment and palliative care at Block Hospice, told you about the four stages through which wounds pass in their development, today, we will talk a little more about the assessment the treatment of this wound. You already know that decubitus ulcers are not just temporary irritations or abrasions but can become a severe and painful discomfort for people bedridden. Therefore, it is essential first, to assess the likelihood of their recovery, as it depends very much on the patient’s condition to what extent they can be treated. Associate Professor Dr. Yordanov tells in detail.

Assessment and treatment

The first step in deciding how to treat bedsores is to assess the likelihood of their healing.

  • Healing of bedsores can be expected when the following factors are present – the patient has a relatively good prognosis (expected survival of the patient is measured in months and years), there are opportunities to ensure and maintain an adequate diet and nutritional status on the patient, and that there are opportunities to restore tissue perfusion in the risk or affected areas;
  • If the patient has an unfavourable prognosis for survival, measured in days and weeks; and/or has poor nutritional status – suffers from severe anorexia/cachexia; and/or the wound does not and cannot have adequate perfusion, then only symptom control is paramount. In these cases, aggressive treatments can be very stressful and cause more suffering to the patient than the potential benefits;

Debridement – removal of dead tissue surgically

It should always be performed under the protection of adequate analgesia! Necrotic tissue must be removed to ensure that the ulcer heals. Surgical removal is the fastest and most effective method when healthy surrounding tissue is preserved.

Note:

  • If the patient is terminal (expects imminent death) and or the wound will never heal, then it is recommended not to attempt surgical debridement (benefit/suffering ratio of the performed manipulation);

Conservative treatment

Medicines containing enzymes are available to remove necrotic tissue applied under occlusive dressings or embedded in the dressing itself. When changing the dressing, the substances degraded under the influence of enzymes are removed mechanically by washing the wound with saline.

Wound cleansing

Cleansing wounds with a relatively favourable prognosis and are expected to heal performed only with non-cytotoxic fluids (e.g. saline). Cytotoxic fluids (e.g. iodine-povidone) kill granulation tissue and slow wound regeneration and recovery.

Clinical recommendation: Do not wash a wound that you want to heal with a liquid that you would not drip into your eye.

Dressing

Living tissue needs moisture to transport oxygen and nutrients. The moist wound environment promotes the migration of fibroblasts and epithelial cells. In the serous wound exudate, the presence of growth factors that accelerate wound healing has been found. In contrast, the dry wound environment is conducive to necrosis development and eschar formation (accumulation of dry dead tissue in the wound, most often in bedsores). Different dressings are currently available on the market. Differing in the time, they may remain on the wound and in the goals pursued – adding or removing fluid to maintain an ideal moist environment conducive to the treatment of decubitus ulcers. A dry decubitus wound should receive sufficient moisture, most often by applying a hypotonic gel (secretes water). In contrast, wet wounds (wounds that exudate) use a hypertonic gel or foam that absorbs water and removes excess moisture from the wound. In the modern treatment of wounds, different dressings are used depending on the characteristics of the wound and the physical condition of the patient.

  • The semi-permeable dressings are made of transparent polyurethane, which allows the passage of water vapor, oxygen and gas exchange and serves as a barrier to incoming bacteria. The advantage of this type of dressings is that they are elastic and flexible and adhere regardless of the shape of the underlying tissue. On the other hand, with their transparency, they provide visibility of the wound from below;
  • Semi-permeable foam dressings have a hydrophobic outer layer and a hydrophilic inner layer. Their advantage is that they absorb the secretions released from the wound, while allowing it to breathe and protect it from external infection. This type of dressings is suitable for treating secretory bedsores and varicose ulcers of the lower extremities. This type of dressings require frequent changes and are not suitable for dry wounds and scars;
  • Hydrogel dressings are insoluble hydrophilic materials derived from synthetic polymers that absorb a significant amount of water. The high water content of the hydrogels (70-90%) helps the healing processes proceed in the proper sequence. The hydrogel is soft and elastic and can be easily applied and removed from the already healed wound without any complications. In addition, hydrogels have a cooling effect and are particularly well tolerated in infected areas. Hydrogels are used on dry chronic wounds, necrotic wounds, bedsores, burn wounds, etc. Hydrogels are flexible, can be applied to any body shape, but have poor mechanical strength;
  • Hydrocolloid dressings are among the most widely used. They consist of an inner colloidal layer and an outer waterproof layer. They are composed of a combination of gelling substances and elastic fibers that allow the wound to breathe while protecting it from external contamination and infection. They are suitable for disabled patients and children due to the lack of pain during removal. They are often used as secondary dressings;
    • Note: the use of an occlusive dressing is not recommended if there is a significant risk of infection;
  • Bioactive wound dressings are made from materials that play an essential role in the healing phases. They are biocompatible, biodegradable and non-toxic. They are produced from natural tissues or synthetically modified collagen, elastin, hyaluronic acid, chitosan or alginate and are used both alone and in combination, depending on the nature and type of wound. Sometimes bioactive dressings are enriched with growth factors and antimicrobial agents to optimize wound healing processes;
    • Alginates: absorb fluid and are suitable for dressing wet wounds, prevent maceration of the surrounding skin from excess fluid, have a hemostatic effect and can reduce the risk of infection;
  • Cotton gauze: used to cover the primary dressing. It is rarely suitable for self-dressing in advanced decubitus ulcer of the skin;

The choice of dressings is determined by the specialists who treat wounds, and their type changes depending on the changes in the wound and the dynamics of external and internal factors.

Antimicrobials

The healing of bedsores is delayed if there is a bacterial infection. Erythema (redness), purulent exudate and fever (fever, fever) are signs of infection. Wound cleansing and topical antibiotics may be sufficient to control superficial infection with minimal involvement of surrounding healthy tissue. Indications for treatment with systemic antibiotics are deep or involve surrounding tissue infections, the clinical picture of developing sepsis (low blood pressure, palpitations, fever, difficulty and rapid breathing, severe general fatigue, which in some cases leads to disorientation) or if the healing of the bedsore is delayed.

Prevention of bedsores

Prevention is much easier to do than to treat existing bedsores. Decubital wounds are not seen in healthy people who control their muscles and respond on time to potential damage caused by pressure. The appearance of the latter in people with reduced mobility can be limited, and their development is prevented by applying specific rules:

  1. Attention to detail:

Constant monitoring of the skin of people at increased risk of developing decubitus ulcers from lying down.

  1. Elimination of risk factors:
    • Regular change of the position of the patient’s body – usually every 2-3 hours (if indicated, more often);
    • Limiting the pressure on the skin – in case of decubitus changes to avoid sitting or lying on the changed parts of the body;
    • Placing a pillow between the patient’s legs when placed in a lateral position;
    • To remove the plastic and/or rubber pads and tarpaulins – they are boiled, folded and pressed against the skin, preventing air from reaching it;
    • Regular change and use of dry linen and blankets, without edges and folds.
    • Avoidance of accidental injuries violating the integrity of the skin such as scratches – short trimming and filing of the patient’s nails so as not to injure themselves;
    • Use of specialized aids against the appearance of bedsores, such as:
      • Anti-decubitus mattress, with variable pressure;
      • Anti-decubitus pillows and circles;
      • Special sheets and mattress covers;
      • Mats, rugs and other specialized equipment facilitating the movement and repositioning of the patient;
    • Encouraging the patient to move within his capabilities and to perform as many activities as possible, gradually increasing the volume of activities to perform independently;
    • Careful and strict maintenance of the hygiene and strength of the patient’s skin:
      • Careful cleansing of the skin, with the application of specialized care products (cleansing and moisturizing creams and oils), and the simultaneous use of powders and lubricants, such as olive oil or greasy creams, should be avoided;
      • Special attention is paid to the intimate hygiene of the patient – cleaning with gentle means and protection from moisture, most often with frequent change of absorbents;
    • Check the condition of the skin every day and timely response to change.
    • Stimulating the skin by massaging with a toning gel and avoiding the use of alcohol, which can over-dry the skin;
    • Provide an appropriate diet to the patient being cared for. If there are no specific contraindications, the daily diet should provide the body with all necessary nutrients, vitamins, and trace elements, including cereals, dairy products, meat, fish, cheese, legumes, vegetables, fruits, and fats. In case of decubitus changes, a diet rich in protein should be used.

Bibliography

  1. Malignant Wounds – Palliative Care Network of Wisconsin [Internet]. [cited 2021 Sep 29]. Available from: https://www.mypcnow.org/fast-fact/malignant-wounds/
  1. Walker P. The pathophysiology and management of pressure ulcers. In:Topics in Palliative     Care, Volume 3. Portenoy RK, Bruera E, eds. New York, NY: Oxford University Press; 1998: pp

253-270.

  1. Walker P. Update on pressure ulcers. Principles & Practice of Supportive Oncology Updates.

2000; 3(6):1-11.

  1. Chrisman CA. Care of chronic wounds in palliative care and end of life. Int Wound Journal 2010;

7: 214-35.

 

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