Issues and dilemmas in the prevention and treatment of pressure ulcers: a review

Treatment approaches of stage III and IV pressure injury in people with spinal cord injury: A scoping review

CONTEXT

The treatment of pressure injury (PI) stage III and IV in people with spinal cord injury or spinal cord disorder (SCI/D) requires a multidisciplinary and surgical involvement.

OBJECTIVES

This scoping review aims to identify published relevant surgical multidisciplinary treatment approaches, describe the elements and evaluate the effectiveness of the approaches.

METHODS

We searched PubMed and Medline databases for studies about treatment approaches for people aged ≥18 years with chronic SCI/D and PI stage III or IV over ischium, trochanter or sacrum published between January 1990 and December 2021 in English or German language. Two independent reviewers screened the articles. One reviewer extracted information on study author(s), year of publication, study title, study design, country of origin, sample size as well as data on elements and effectiveness of the approaches.

RESULTS

10 different approaches were described in two retrospective cohort studies, three case series, five discussion papers, one review and one guideline. All approaches included debridement, flap surgery, pressure relief and immobilization as well as infection control. Some approaches described elements such as risk screening (7/10), osteomyelitis treatment (8/10), nutritional therapy (8/10), physiotherapy, occupational therapy and psychology (6/10), spasticity control (7/10), and prevention and education (6/10). Only one study reported on the effectiveness of the approaches.

CONCLUSION

There are key elements for surgical multidisciplinary treatment approaches. However, due to differences in the content of some of these elements and missing elements in some approaches, comparability is difficult and the effectiveness of the complex approaches remains uncertain.

A Prospective Study of Pressure Injury Healing Rate and Time and Influencing Factors in an Acute Care Setting

OBJECTIVE

To determine pressure injury (PI) healing rate and time and identify influencing factors.

METHODS

A prospective cohort research design was used. Data collection was performed between May 2015 and August 2018. The study participants were 77 inpatients who developed at least one PI during their stay in a university hospital. Researchers assessed participants' demographic (age, sex); physical (incontinence, activity of daily living, and nutrition status); physiologic (serum total protein, albumin, and creatinine, blood glucose, and hemoglobin levels); and disease- (diagnosis, number of comorbidities, and cardiovascular comorbidity), wound- (PI stage and size at first detection, and Pressure Ulcer Scale for Healing score), and treatment-related (IV nutrition supply and albumin infusion) factors.

RESULTS

Across the 77 patients, 91 PIs developed. Of these, 54 (59.3%) healed with a mean healing time of 17.63 days. The healing rate was better, and the healing time was shorter for stage 2 PIs compared with unstageable or deep-tissue PIs. Factors influencing PI healing rate were number of comorbidities, cardiovascular comorbidity, incontinence, PI stage at first detection, IV nutrition supply, and mean serum creatinine level. Factors influencing PI healing time were number of comorbidities, cardiovascular comorbidity, and PI stage at first detection.

CONCLUSIONS

To reduce hospital stays, PI-related complications, and mortality, evidence-based management strategies for PIs are needed. The findings of the present study may contribute to the development of such strategies.

Wound tissue segmentation by computerised image analysis of clinical pressure injury photographs: a pilot study

OBJECTIVE

Wound tissues can provide ample information about the wound development and healing process. However, the manual identification and measurement of wound tissue types is time-consuming and challenging due to the complexities of pressure injuries (PI). This study aims to develop an image analysis algorithm to automatically identify and differentiate wound tissue types from PI wound beds.

METHOD

This was a cross-sectional algorithm development study. PI photographs were obtained from a western Pennsylvania hospital. We used our previously developed wound bed segmentation tool to identify PI wound beds. We then used the k-means clustering method to classify the subzones on the wound beds. Finally, the support vector machine classifier was used to identify the classified subzones to certain types of wound tissue.

RESULTS

An image analysis algorithm was developed, using 64 selected PI photographs, to automatically identify different wound tissues for PIs.

CONCLUSION

Validation of the wound tissue identification of the PIs by image analysis algorithm demonstrated that our image analysis algorithm is a reliable and objective approach to monitoring wound healing progress through clinical PI photographs, and offers new insight into PI evaluation and documentation.

DECLARATION OF INTEREST

The authors have no conflicts of interest to declare.

Bedsores Management: Efficiency Simulation of a New Mattress Design

Bedsores, also known as pressure ulcers, are wounds caused by the applied external force (pressure) on body segments, thereby preventing blood supply from delivering the required elements to the skin tissue. Missing elements hinder the skin’s ability to maintain its health. It poses a significant threat to patients that have limited mobility. A new patented mattress design and alternative suggested designs aimed to reduce pressure are investigated in this paper for their performance in decreasing pressure. A simulation using Ansys finite element analysis (FEA) is carried out for comparison. Three-dimensional models are designed and tested in the simulation for a mattress and human anthropometric segments (Torso and Hip). All designs are carried out in solidworks. Results show that the original design can redistribute the pressure and decrease it up to 17% less than the normal mattress. The original design shows better ability to decrease the absolute amount of pressure on the body. However, increasing the surface area of the movable parts results in less pressure applied to the body parts. Thus, this work suggests changing the surface area of the cubes from 25 to 100 cm².

Assessment of the extension of pressure ulcers into soft tissue and osteomyelitis diagnosis using 18F-FDG PET/CT

The precise assessment of pressure ulcer extension in patients with neurological diseases has crucial therapeutic implications, especially in the early detection of fistula to interior structures and osteomyelitis. Two case reports are presented on patients with a similar ischial ulcer, in whom an ¹⁸F-FDG PET/CT study enabled a precise assessment of infectious complications in underlying tissues. These cases support the implementation of ¹⁸F-FDG PET/CT as a first-line technique in their management.

Prevention and Treatment of Pressure Ulcers

Pressure ulcers are a serious health concern for elders in acute care, long-term care, and home care settings. The occurrence of a pressure ulcer is considered a sentinel event in terms of quality of care. Pressure ulcers may result in significant morbidity and mortality and are associated with high cost in terms of human suffering, cost of treatment, and possible litigation. Several risk factors have been identified for the development of pressure ulcers. Identification of elderly patients at risk of pressure and implementation of preventative measures are essential. Management of a pressure ulcer involves debridement, cleansing, selection of an appropriate dressing, and prevention of infection. This article reviews suggested guidelines for the prevention and management of pressure ulcers.

Pressure ulcer prevalence, use of preventive measures, and mortality risk in an acute care population: a quality improvement project

The primary aim of this quality improvement project was to determine pressure prevalence, risk of mortality, and use of preventive measures in a group of hospitalized patients. Two hundred fifty-eight patients recruited from Skaraborg Hospital in Sweden were assessed. A 1-day point prevalence study was carried out using a protocol advocated by the European PU Advisory Panel. Patients' age, gender, severity of PU (grades I-IV), anatomical location of PU, and use of preventive measures were recorded. The Swedish language version of the Modified Norton Scale was used for PU risk assessment. Data were collected by nurses trained according to the Web-based training: PU classification, "ePuclas2." After 21 months, a retrospective audit of the electronic records for patients identified with pressure ulcers was completed. The point prevalence of pressure ulcers was 23%. The total number of ulcers was 85, most were grade 1 (n = 39). The most common locations were the sacrum (n = 15) and the heel (n = 10). Three percent of patients (n = 9) had been assessed during their current hospital stay using a risk assessment tool. There was a statistically significant relationship between pressure ulcer occurrence and a low total score on the Modified Norton Scale. The patients' ages correlated significantly to the presence of a pressure ulcer. Patients with a pressure ulcer had a 3.6-fold increased risk of dying within 21 months, as compared with those without a pressure ulcer. Based on results from this quality improvement project, we recommend routine pressure ulcer risk assessment for all patients managed in a hospital setting such as ours. We further recommend that particular attention should be given to older and frail patients who are at higher risk for pressure ulcer occurrence and mortality.

Development and evaluation of a self-regulating alternating pressure air cushion

PURPOSE

To investigate the effect of alternating air cells of a newly developed dynamic cushion on interface pressure and tissue oxygenation levels.

METHOD

This cross-over experimental study included 19 healthy volunteers. The dynamic cushion used has an automatic self-regulating alternating pressure air-cell system with 35 small and four large air cells for maintaining posture while seated. This cushion also has 17 bottoming-out detectors that automatically inflate the air cells to release a high interface pressure. To assess the effect of this alternating system, participants sat on the new cushion with an alternating system or static system for 30 min and then performed push-ups. The interface pressure was monitored by pressure-sensitive and conductive ink film sensors and tissue oxygenation levels were monitored by near-infrared spectroscopy. A reactive hyperaemia indicator was calculated using tissue oxygenation levels as an outcome measure.

RESULTS

The peak interface pressure was not significantly different between the groups. The reactive hyperaemia indicator was significantly higher in the static group than in the alternating group.

CONCLUSIONS

An alternating system has beneficial effects on blood oxygenation levels without increasing interface pressure. Therefore, our new cushion is promising for preventing pressure ulcers with patients with limited ability to perform push-ups. Implications for Rehabilitation A dynamic cushion was developed, which consists of a uniquely-designed air-cell layout, detectors for bottoming out, and an alternating system with multiple air-cell lines. The alternating system did not increase interface pressure and it significantly reduced reactive hyperaemia after 30 min of sitting in healthy volunteers. This cushion is a new option for individuals who require stable posture but have limitations in performing scheduled push-ups for prevention of pressure ulcers.

Heel damage and epidural analgesia: is there a connection?

OBJECTIVE

To determine heel pressure injury prevalence in surgical patients prescribed epidural analgesia and identify intrinsic and extrinsic factors associated with heel damage in this patient cohort.

METHOD

A descriptive study was used to investigate intrinsic and extrinsic variables associated with recorded heel observations at a private hospital in Victoria, Australia. We recruited a sample of 29 consecutive non-emergency participants undergoing general anaesthesia for major surgery, who were prescribed epidural analgesia postoperatively. A total of 58 heel observations were made.

RESULTS

Heel damage prevalence in the study sample was 13.8% (n=8).

CONCLUSION

Intrinsic factors associated with this complication included intra- and postoperative hypotension, vascular disease, smoking, chronic obstructive pulmonary disease, and multiple disease burdens. Extrinsic factors associated with heel damage included thromboembolic deterrent stockings and the postoperative ward use of heel protectors designed for use in operating theatres. It is hoped that the study findings will assist improvements in the assessment of heel damage risk and promote the pressure prevention strategies required by this patient cohort.

Pressure ulcers in orthopaedics

Pressure ulcers can be a devastating complication in the care of orthopaedic patients. Their presence leads to increased morbidity, mortality, and cost of care. Therapy and rehabilitation cannot progress on a normal postoperative course in the patient with a pressure ulcer. Risk factors for the development of pressure ulcers include spinal cord injury, advanced age, and cognitive impairment. Several grading scales have been developed for the assessment of pressure ulcer. Frequent patient turning, close monitoring, and frequent skin checks are important factors in the prevention of pressure ulcer.

Wound healing in older adults

Chronic wounds affect a substantial number of individuals throughout the world, and impose a significant psychological, physical and economic burden. As the population ages, the incidence of chronic wounds is also expected to rise. Clinicians struggle to find the optimal approaches to prevention and treatment of these nonhealing or slow-healing wounds. This review discusses current best practices and evidence-based recommendations for preventing and managing chronic wounds in general, as well as pressure ulcers, diabetic foot ulcers and venous leg ulcers specifically. This review highlights the significant gaps and inconsistencies in the current evidence base for chronic wound care, which have hindered making substantial progress in improving wound healing rates. It concludes with recommendations for improving the research and clinical knowledge base related to optimal wound-care practices.

Efficacy and safety of ornithine alpha-ketoglutarate in heel pressure ulcers in elderly patients: results of a randomized controlled trial

OBJECTIVE

Pressure ulcers affect predominantly the elderly and nutritional status is a known risk factor. Guidelines on pressure ulcers provide recommendation on nutritional management. Ornithine alpha-ketoglutarate (OKG) is an adjuvant treatment in undernourished elderly patients or in patients with hypercatabolism states. It is a precursor of different amino-acids which play a role in the process of healing. The objective of the study is to determine the efficacy of OKG on pressure ulcer area reduction after six weeks of treatment.

DESIGN

Multi-centre, international, randomized, comparative, double blind, parallel groups, placebo-controlled study.

PARTICIPANTS

160 patients (ITT population) aged over 60 years with a heel pressure ulcer at stage II or III.

INTERVENTION

Patients received OKG (n=85) or placebo (n=75) once a day for 6 weeks.

MEASUREMENTS

Ulcer area was measured each week, using a tracer. The primary endpoint was the percentage reduction of the surface at the final visit: [(Wound areatn - Wound areat0)/ (Wound areat0)].

RESULTS

At inclusion, ulcer area distribution deviated from normal distribution (median ulcer area OKG 6.6 cm(2), placebo 3.9 cm2, p=0.044, Mann-Whitney test). As healing is strongly related to baseline ulcer area, the abnormal distribution was a major bias. Therefore it was decided to perform the analysis on 2 sub-groups of patients according to the mean ulcer area, i.e. above or below 8 cm2. The mean wound area reduction for baseline area 8 cm2 no between group differences on either parameter was detected. When closure rate is considered, a significant difference in favor of OKG group is observed (- 0.07 cm2/day in the OKG group and - 0.04 cm2/day in the placebo groups respectively p=0.007, Mann-Whitney test). Thirty serious adverse events were reported in 28 patients (15 allocated to OKG and 13 to placebo). None of them was considered treatment related.

CONCLUSION

This clinical trial supports a potential benefit of OKG 10g daily in the subgroup of patients with pressure ulcers Collapse

Key Words Collapse

MESH Headings

• Aged
• Aged, 80 and over
• Double-Blind Method
• Female
• Foot Ulcer/drug therapy
• Foot Ulcer/pathology
• Heel/pathology
• Humans
• Male
• Ornithine/adverse effects
• Ornithine/analogs & derivatives
• Ornithine/therapeutic use
• Pressure Ulcer/drug therapy
• Pressure Ulcer/pathology
• Reference Values
• Skin/drug effects
• Skin/pathology
• Statistics, Nonparametric
• Wound Healing/drug effects

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Grants Collapse

Affiliation(s)

S Meaume Department of Gerontology, Charles Foix Hospital, Ivry-sur-Seine, Paris
J C Kerihuel
T Constans
L Teot
E Lerebours
J Kern
I Bourdel Marchasson

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Wound care in the geriatric client

With our aging population, chronic diseases that compromise skin integrity such as diabetes, peripheral vascular disease (venous hypertension, arterial insufficiency) are becoming increasingly common. Skin breakdown with ulcer and chronic wound formation is a frequent consequence of these diseases. Types of ulcers include pressure ulcers, vascular ulcers (arterial and venous hypertension), and neuropathic ulcers. Treatment of these ulcers involves recognizing the four stages of healing: coagulation, inflammation, proliferation, and maturation. Chronic wounds are frequently stalled in the inflammatory stage. Moving past the inflammation stage requires considering the bacterial burden, necrotic tissue, and moisture balance of the wound being treated. Bacterial overgrowth or infection needs to be treated with topical or systemic agents. In most cases, necrotic tissue needs to be debrided and moisture balance needs to be addressed by wetting dry tissue and drying wet tissue. Special dressings have been developed to accomplish these tasks. They include films, hydrocolloids, hydrogel dressings, foams, hydrofibers, composite and alginate dressings.

Factors Influencing Pressure Ulcer Healing in Adults Over 50: An Exploratory Study

OBJECTIVE

The purpose of this study was to determine which demographic, clinical, and treatment factors influenced chronic pressure ulcer healing, and to identify the implications for pressure ulcer care being delivered in skilled nursing facilities.

DESIGN

A multisite retrospective chart review was conducted using a structured data abstraction form and protocol.

SETTING

Data collection took place in 3 geographically disperse areas of the country, with subjects having received wound care in hospitals, clinics, nursing homes, and home care.

PARTICIPANTS

Subjects whose charts were reviewed were 50 years of age or older, had at least 1 diagnosed chronic pressure ulcer, and had 3 to 6 months of data available for abstraction. Stage I ulcers were excluded from the analysis.

MEASURES

The structured data collection form included demographics, clinical variables, wound characteristics, and outcomes. The variables ulcer size, exudate type and amount, and necrotic tissue type were combined into a single wound severity score.

RESULTS

Bivariate analyses showed that insurance type, secondary diagnoses of cardiovascular disease and pulmonary disease, initial ulcer size and stage, dressing type changes, use of topical antiseptics, type of debridement, category of dressing, use of hydrocolloid or wet-to-dry dressings, antibiotic administration, and appropriateness of selected dressing and management of necrosis were all significantly associated with healing within 6 months. Logistic regression models identified the following as the most significant predictors of healing: Medicaid, secondary diagnosis of cardiovascular disease, dressing type changed, topical antiseptics, antibiotic administration, pressure relief device, lack of exudate management dressing for moderate or large exudate wound, and lack of debridement of wounds with yellow slough, all decreased the odds of healing; use of exudate management dressings on wounds with no documented exudate increased the odds of healing.

CONCLUSION

Pressure ulcer healing rates overall could be improved if clinicians better matched the characteristics of the wound with the decision to debride and the selection of the optimal dressing. Healing within nursing homes might be improved with less use of enzymatic debridement and antibiotics and more frequent application of hydrocolloid dressings.

Assessment and management of chronic pressure ulcers in the elderly

Pressure ulcers remain a complex and costly problem to the health care system. As the population ages, a greater number of individuals will be at high risk for developing pressure ulcers. An understanding of the physiologic changes that occur with aging skin is important in preventing and treating chronic wounds. Risk factor assessment and modification, when possible, can help to reduce the development of pressure ulcerations. Although the goal continues to be prevention, once a pressure ulcer does occur, a systematic and comprehensive approach to assessment and treatment is necessary to reduce healing times.

Skin Fails Too

OBJECTIVE

To identify what has been published in the literature about acute and chronic skin failure and to propose a working definition of this phenomenon.

DESIGN

A systematic review of MEDLINE and CINAHL to determine what has been published in the literature on the topics of skin failure, acute skin failure, chronic skin failure, multiple organ failure, end-of-life skin deterioration, and pressure ulcers in hospice from 1984 to 2005.

MAIN OUTCOME MEASURES

Published papers were reviewed for content related to acute, chronic, and end-stage skin failure.

MAIN RESULTS

Seven articles were identified that referenced either acute, chronic, or end-stage skin failure. Additional information was identified that discussed the processes of acute and chronic skin failure and pressure ulcers in individuals in hospice care or at the end of life. Care considerations and dilemmas related to a curative versus palliative goal in wound healing were discussed.

CONCLUSIONS

Minimal literature exists on skin failure, yet caregivers and the public must be aware of, assess for, and consider this phenomenon in their care. Based on this literature review, skin failure was defined by the authors as an event in which the skin and underlying tissue die due to hypoperfusion that occurs concurrent with severe dysfunction or failure of other organ systems. Skin failure can be categorized as acute, chronic, or end stage. Pressure ulcers, a type of skin death, frequently occur in persons with a heavy disease burden, especially those at or near the end of life, despite good care.

Escarres dans un hôpital universitaire de court séjour

OBJECTIVES

To determine the prevalence of pressure sores, their risk factors, and the responsible microbial agents in an acute-care hospital and to evaluate their management.

METHOD

A prevalence survey was conducted from 5 July through 9 July 2004. Investigators completed a standardized questionnaire for each hospitalized patient, including demographic data (age, sex, previous hospitalizations, etc.) and Braden scale risk factors (sensory perception, humidity, activity, mobility, nutrition, and friction and shear). Two experts in skin care detected pressure sores by physical examination of the patients. Each pressure sore was swabbed and inoculated on selective media. Management was evaluated by reviewing the clinical charts of each patient with a pressure sore.

RESULTS

The study included 535 adult patients (aged 59 +/- 19 years): 75 ulcer sores were observed in 37 patients (prevalence=6.9%). Stage I sores accounted for 24% of the total, stage II for 29%, stage III 31%, and stage IV 16%. The most frequent site was the heel (41%), followed by the sacrum (20%), elbow (11%), back (7%) and ischial tuberosities (7%). Sixty (80%) were acquired while hospitalized. Age-adjusted multivariate analyses found that the risk factors significantly associated with pressure sores were Braden score< or =15 (OR=5.9, 95% CI: 2.4-13.7, p<0.0001) and previous pressure sores (OR=5.0 95% CI: 2.2-11.6, p<0.0001). Eleven sores (24.5%), mostly stage III and IV, were colonized by multiple-drug-resistant bacteria (i.e., methicillin resistant Staphylococcus aureus, extended spectrum beta-lactamase Enterobacteriaceae). Seven (9.3%) of the 75 ulcers were diagnosed only during the survey, by the experts; of the 68 diagnosed before the survey, 57 (83.8%) had been under treatment. Treatment was considered inappropriate according to French guidelines in 31.6% of the cases.

CONCLUSION

This prospective prevalence study resulted in better awareness of the patients at risk for pressure sores. It also made the recently created mobile geriatrics unit better known within the hospital.

Risk assessment scales for pressure ulcer prevention: a systematic review

AIM

This paper reports a systematic review conducted to determine the effectiveness of the use of risk assessment scales for pressure ulcer prevention in clinical practice, degree of validation of risk assessment scales, and effectiveness of risk assessment scales as indicators of risk of developing a pressure ulcer.

BACKGROUND

Pressure ulcers are an important health problem. The best strategy to avoid them is prevention. There are several risk assessment scales for pressure ulcer prevention which complement nurses' clinical judgement. However, some of these have not undergone proper validation.

METHOD

A systematic bibliographical review was conducted, based on a search of 14 databases in four languages using the keywords pressure ulcer or pressure sore or decubitus ulcer and risk assessment. Reports of clinical trials or prospective studies of validation were included in the review.

FINDINGS

Thirty-three studies were included in the review, three on clinical effectiveness and the rest on scale validation. There is no decrease in pressure ulcer incidence was found which might be attributed to use of an assessment scale. However, the use of scales increases the intensity and effectiveness of prevention interventions. The Braden Scale shows optimal validation and the best sensitivity/specificity balance (57.1%/67.5%, respectively); its score is a good pressure ulcer risk predictor (odds ratio = 4.08, CI 95% = 2.56-6.48). The Norton Scale has reasonable scores for sensitivity (46.8%), specificity (61.8%) and risk prediction (OR = 2.16, CI 95% = 1.03-4.54). The Waterlow Scale offers a high sensitivity score (82.4%), but low specificity (27.4%); with a good risk prediction score (OR = 2.05, CI 95% = 1.11-3.76). Nurses' clinical judgement (only considered in three studies) gives moderate scores for sensitivity (50.6%) and specificity (60.1%), but is not a good pressure ulcer risk predictor (OR = 1.69, CI 95% = 0.76-3.75).

CONCLUSION

There is no evidence that the use of risk assessment scales decreases pressure ulcer incidence. The Braden Scale offers the best balance between sensitivity and specificity and the best risk estimate. Both the Braden and Norton Scales are more accurate than nurses' clinical judgement in predicting pressure ulcer risk.

Pressure ulcers: the great insult

Pressure ulcers are a common and frustrating problem. Pressure ulcers increase demands on health care resources and are sometimes a source of malpractice litigation. Skin breakdown, often an iatrogenic complication of hospitalization, increases the length of stay and contributes to mortality and morbidity. Long-term care facilities are under increasing regulatory pressure to reduce rates of pressure ulcer occurrence. The process-outcome link continues to escape us. Processes of care seem disjointed. Numerous studies show a failure to implement what we know. When pressure ulcer risk is identified, preventive measures often are not implemented. The literature is replete with reports of quality improvement activities that enumerate multiple opportunities to improve care related to pressure ulcers. Various quality improvement strategies for pressure ulcer prevention and management have been produced, but recommendations are not always applied to practice. When studies compared various outcomes before and after implementation of guidelines, most of the evidence was clinical audit data. Overall, active strategies were associated with better outcomes and passive strategies with poorer ones. Baier et al reported improvement in processes of care after using a structured quality improvement approach in the long-term care setting. Targeted education sessions were common to all studies reporting successful outcomes. Multidisciplinary wound care teams that conduct rounds at the bedside are highly recommended to enhance patient outcomes.Functioning interdisciplinary teams clearly represent an important approach to error reduction. To close the gap between risk identification and pressure ulcer prevention, we should develop active multidisciplinary wound care teams and "Strive for Six Sigma in Pressure Ulcer Care".

Microbiology of chronic leg and pressure ulcers: clinical significance and implications for treatment

Chronic pressure ulcers and leg ulcers are common, especially in the elderly, and are a source of much distress and disability. Health care providers must distinguish between clinically unimportant but predictable colonization of these wounds and clinically relevant infection.Infection may present as increased local pain, cellulitis, local abscess,necrotizing fasciitis, osteomyelitis, bacteremia, or sepsis. For most of these conditions, systemic antibiotics are necessary. The use of topical antimicrobial agents as a means of promoting healing in clinically uninfected wounds is a subject of active investigation at this time. Currently, evidence is insufficient to support routine use of anti-microbial agents for this purpose. A quantitative tissue culture taken from the ulcer bed, revealing greater than 10(5) organisms/g of tissue appears to increase the risk of failure of ulcer wound closure by graft or flap. A short course of topical or systemic antibiotics before surgery in these instances is advisable.

Overview: acute and chronic wounds

Knowledge of normal wound healing and the changes associated with chronic wounds have advanced significantly. Distinct characteristics identified through basic and clinical studies are found in nonhealing wounds, including bacterial and growth factor imbalances, increased inflammatory responses, and proteolytic forces that tip the balance toward tissue degradation rather than repair. This article describes the alterations that reduce healing and that also have important implications for the management of chronic wounds and presents a focus for future developments in wound therapy.

An evaluation of the Waterlow pressure ulcer risk-assessment tool

The National Institute for Clinical Excellence (NICE, 2001) stated that in order to achieve clinical governance strategies, risk management in the form of pressure ulcer risk assessment will contribute to improved quality of patient care. Risk-assessment tools must display high-predictive values, be highly sensitive and specific, reliable, and easy and convenient to use. Despite their extensively documented poor performance, pressure ulcer risk-assessment scales play a primary role in the prevention and management of pressure ulcers. The tools attempt to determine patients' risk status by quantifying a range of the most commonly recognized risk factors. Although there are over 40 different assessment tools, the Waterlow pressure ulcer risk-assessment tool is the tool that is most widely used in the UK. This article aims to review studies relating to the reliability, content validity, predictive validity, concurrent validity and the construct validity of the Waterlow pressure ulcer risk-assessment tool.

The relationship between dermal pressure ulcers, oxygenation and perfusion in mechanically ventilated patients

BACKGROUND

More than 1.5 million hospitalized patients develop dermal pressure ulcers (DPUs) annually, which increases cost and prolongs length of stay. Mechanically ventilated patients may be at a high risk for DPU development, but research has not focused on the prevalence of dermal pressure ulcers in this population or the factors associated with dermal pressure ulcer development.

OBJECTIVES

To determine the prevalence of dermal pressure ulcers in subjects receiving mechanical ventilation and to describe the relationship between systemic oxygenation, tissue perfusion, and the prevalence of dermal pressure ulcers.

METHODS

Subjects from an Intensive Care Unit in a Midwestern hospital in the United States were recruited into this descriptive, correlational study following intubation. Variables included: demographics, general subject status (weight, serum albumin), ventilatory status, oxygenation status (arterial blood gas analysis including concentration of hydrogen ions, partial pressure of carbon dioxide, partial pressure of oxygen, and amount of oxygen carried by hemoglobin), perfusion status (mean arterial pressure, heart rate, urine output), and skin condition. The Braden Scale was used to measure the risk of skin breakdown, with any skin breakdown being classified in stages ranging from I to IV (I having minimal breakdown, IV having maximal breakdown). Braden Scores range from 6 to 23, with a score of 6 indicating high risk and a score of 23 indicating low risk. Data were collected every other day after admission to the Medical Intensive Care Unit until extubation, transfer, or death.

RESULTS

Subjects (n = 40) were primarily Caucasian (77.5%), having a mean age of 56.4 years (+/-14.6 years). Half of the sample was male (50%). Twenty percent of the sample developed DPUs. A Pearson's correlation identified the significant associations between the Braden Score and MAP, PaCO(2), largest weight fluctuation in a 3-day period, and change in weight from admission to discharge. Surprisingly, the lowest Braden Score was not significantly associated with the development of DPUs.

CONCLUSIONS

Mechanically ventilated patients are vulnerable to developing dermal pressure ulcers as evidence by 20% of the subject population developing a dermal pressure ulcer. The most significant factors related to a low Braden Score in this group are fluid shifts and fluid weight gain. This may be an important predictor of dermal pressure ulcers not currently assessed clinically.

A controlled, randomized, comparative study of a radiant heat bandage on the healing of stage 3–4 pressure ulcers: A pilot study

OBJECTIVES

Pressure ulcers, like other chronic wounds, fail to proceed through an orderly and timely process to produce anatomical or functional integrity. Treatment of pressure ulcers is directed to improving host factors and providing an optimum wound environment. In addition to providing a moist wound environment, it has been theorized that preventing hypothermia in a wound and maintaining a normothermic state might improve wound healing.

DESIGN/SETTING

Forty-one subjects with a stage 3 or stage 4 truncal pressure ulcer >1.0 cm(2) were recruited from outpatient clinics, long-term care nursing homes, and a rehabilitation center. The experimental group was randomized to a radiant-heat dressing device and the control group was randomized to a hydrocolloid dressing, with or without a calcium alginate filler. Subjects were followed until healed or for 12 weeks.

RESULTS

Eight subjects (57%) in the experimental group had complete healing of their pressure ulcer compared with 7 subjects (44%) with complete healing in the control group (P = .46).

CONCLUSION

Although a 13% difference in healing rate between the two arms of the study was found, this difference was not statistically significant. At almost all points along the healing curve, the proportion not healed was higher in the control arm.

The effectiveness of oral nutritional supplementation in the healing of pressure ulcers

OBJECTIVE

To investigate the effectiveness of an oral nutritional supplement that is rich in protein and enriched with arginine, vitamin C and zinc on the healing of pressure ulcers.

METHOD

Thirty-nine patients with grade III or IV pressure ulcers were enrolled into this open intervention study. Subjects received an oral nutritional supplement daily for three weeks. Wound area and the wound condition of the ulcers were assessed weekly.

RESULTS

After three weeks of supplementation, median wound area reduced significantly (p < 0.001) from 23.6 cm2 (1.6-176.6 cm2) to 19.2 cm2 (1.2-132.7 cm2), a reduction of 29%. Median healing of wound area was 0.34 cm2 per day, taking approximately two days to heal 1 cm2. Within three weeks the amount of exudate in infected ulcers (p = 0.012) and the incidence of necrotic tissue (p = 0.001) reduced significantly.

CONCLUSION

Nutritional intervention in the form of a specific oral nutritional supplement resulted in a significant reduction in wound area and an improvement in wound condition in patients with grade III and IV pressure ulcers within three weeks.

Wound care for elderly patients: advances and clinical applications for practicing physicians

Chronic ulcers (wounds) are commonly encountered in medical practice, particularly in elderly patients who have chronic medical conditions. Health care providers must be adept at diagnosing chronic ulcers and optimizing medical treatment. We describe the best medical practice for the 4 common types of chronic ulcers: pressure ulcers, ischemic ulcers, venous ulcers, and neuropathic ulcers. We emphasize the importance of nutrition and proper wound care as a foundation for the management of all chronic ulcers. There is a unique therapeutic goal for each chronic ulcer. Pressure relief should be provided for both pressure ulcers and neuropathic ulcers. Ischemic ulcers require revascularization. Patients with venous ulcers need adequate edema control. We outline advances in each of these areas and discuss the newest developments in wound care, including growth factors, hyperbaric oxygen, and vacuum-assisted devices. Chronic ulcers in elderly patients can heal with proper diagnosis and good medical care.

The development of an educational collaborative to address comprehensive pressure ulcer prevention and treatment

The prevention and treatment of pressure ulcers is a growing public policy concern. Driven by a more informed consumer and the exploding costs of care, policy makers are looking for ways to integrate health-care research and long-term care practices in an effort to improve the quality of care and ultimately reduce costs. This paper presents a case study that demonstrates how training is being integrated at the facility level, utilizing a collaborative. The collaborative was a joint public-private partnership supported through resources from state, federal, and private agencies, with an overarching goal of delivering high-quality, easily accessible geriatric education and training. Direct care providers and other practitioners were recruited to attend a live, interactive videoconference that featured nationally known experts. The content of the educational program was drawn from nationally accepted guidelines that discuss appropriate procedures for wound cleansing, dressings, positioning techniques, proper nutrition and risk assessment protocols. Evaluation of the program indicated that the highest-rated objectives related to the application of training content in the implementation of treatment and prevention procedures important to quality patient care. An examination of publicly available data revealed that an escalating increase in the percentage of facilities in the state cited for deficiencies because of the incidence of pressure ulcers from 1996 to 1999 was reversed in 2000, subsequent to the videoconference. Future programs are planned to sustain the availability of opportunities for practitioners to get critical updates from the experts in the field via live interactive sessions.

Skin Care Intervention for Patients Having Cardiac Surgery

• Background Pressure ulcers are a major problem after cardiovascular surgery, occurring in 9.2% to 38% of patients.

• Objectives To determine the effectiveness of a skin care intervention program in preventing development of ulcers or progression from one stage to another and to determine the extent to which selected risk factors were associated with development and progression of pressure ulcers.

• Methods A simple interrupted time series design was used. The protocol involved interrelated assessment, staging, and type of intervention provided. The Braden Scale was used to determine risk for skin breakdown.

• Results Of the 351 patients in the study, 327 (93%) maintained skin integrity and 24 (7%) had skin breakdown. Breakdown by stages was as follows: stage 1, 62% (n = 15); stage 2, 29% (n = 7); stage 3, 4% (n = 1); and stage 4, 4% (n = 1). Age, sex (female), and heart failure were statistically significant risk factors for breakdown (P = &lt;.001, .02, and .02, respectively). The mean scores on the Braden Scale of the breakdown group differed significantly from those of the skin integrity group from days 2 through 5 after surgery (P = .01). Seventeen (71%) of the breakdowns occurred during the first 4 days after surgery.

• Conclusions Skin assessments and nursing interventions should be increased on the day of surgery and the first to fifth postoperative days, including multiple assessments and skin care focused on maintaining skin integrity.

Invited review: Aging and energy balance

Humans over 70 yr of age often lose weight. This appears to be due to a physiological anorexia of aging as well as a loss of lean mass (sarcopenia) and, to a lesser extent, fat mass. The causes of the physiological anorexia of aging include changes in taste and smell and a decrease in adaptive relaxation of the fundus of the stomach, which leads to more rapid antral filling and early satiation. In addition, basal and stimulated levels of the satiating hormone, cholecystokinin, are increased. In men, the decline in testosterone leads to an increase in leptin and a loss of lean mass. Although resting metabolic rate declines with aging, this is mainly due to the decline in lean body mass. Energy metabolism is also decreased due to a decline in Na+-K+-ATPase activity, decreased muscle protein turnover, and possibly changes in mitochondrial membrane protein permeability. Physical energy expenditure declines with aging. Meal-induced thermogenesis shows a delay to peak, possibly due to a delay in gastric emptying. Inadequate data are available on the effect of aging in humans on other energy-producing mechanisms such as adaptive thermogenesis. These physiological changes place older men and women at major risk of developing pathological weight loss when they develop disease states, especially those associated with cytokine elaboration.

Effects of 810 nm laser irradiation on in vitro growth of bacteria: comparison of continuous wave and frequency modulated light

BACKGROUND AND OBJECTIVES

Low intensity laser therapy may modify growth of wound bacteria, which could affect wound healing. This study compares the effects on bacteria of 810 nm laser using various delivery modes (continuous wave or frequency modulated light at 26, 292, 1000, or 3800 Hz).

STUDY DESIGN/MATERIALS AND METHODS

Staphylococcus (S.) aureus, Escherichia (E.) coli, and Pseudomonas (P.) aeruginosa were plated on agar and then irradiated (0.015 W/cm(2); 1-50 J/cm(2)) or used as controls (sham irradiated); growth was examined after 20 hours of incubation post exposure.

RESULTS

There were interactions of species and modulation frequency in the overall effects of irradiation (P = 0.0001), and in the radiant exposure mediated effects (P = 0.0001); thus individual frequencies and each bacterium were analysed separately. Bacteria increased following 3800 Hz (P = 0.0001) and 1000 Hz (P = 0.0001) pulsed irradiation; at particular radiant exposures P. aeruginosa proliferated significantly more than other bacteria. Pulsed laser at 292 and 26 Hz also produced species-dependent effects (P = 0.0001; P = 0.0005); however, the effects for different radiant exposures were not significant. Bacterial growth increased overall, independent of species, using continuous mode laser, significantly so at 1 J/cm(2) (P = 0.02). Analysis of individual species demonstrated that laser-mediated growth of S. aureus and E. coli was dependent on pulse frequency; for S. aureus, however, there was no effect for different radiant exposures. Further tests to examine the radiant exposure effects on E. coli showed that growth increased at a frequency of 1000 Hz (2 J/cm(2); P = 0.03). P. aeruginosa growth increased up to 192% using pulsed irradiation at 1000-3800 Hz; whereas 26-292 Hz laser produced only a growth trend.

CONCLUSIONS

The findings of this study point to the need for wound cultures prior to laser irradiation of infected wounds. Similar investigations using other common therapeutic wavelengths are recommended.