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壓瘡 林明憲醫師 台北榮總高齡醫學中心 國立陽明大學醫學系 103.09.13.. Definition Any lesion caused by unrelieved pressure resulting in damage of underlying tissue Areas of local.

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Presentation on theme: "壓瘡 林明憲醫師 台北榮總高齡醫學中心 國立陽明大學醫學系 103.09.13.. Definition Any lesion caused by unrelieved pressure resulting in damage of underlying tissue Areas of local."— Presentation transcript:

1 壓瘡 林明憲醫師 台北榮總高齡醫學中心 國立陽明大學醫學系 103.09.13.

2 Definition Any lesion caused by unrelieved pressure resulting in damage of underlying tissue Areas of local tissue trauma, usually developing where soft tissues are compressed between bony prominences and any external surface for prolonged time periods

3 A sign of local tissue necrosis Most commonly found over bony prominences subjected to external pressure Most common locations: sacrum, ischial tuberosities, trochanters and heels —sacrum and heels most frequent Synonymous terms —Pressure ulcer —Decubitus ulcer —Bedsore

4 Epidemiology Prevalence Hospitalized elderly: 15% Patients expected to be bedridden or chair bound > 1 week, ≥ stage II pressure ulcers: 28% Prevalence varies by setting —Nursing home = 2.3% to 28% —Home care = 6% to 9% —Outpatient clinic = 1.6%

5 Epidemiology Incidence Incidence during hospitalization: 8~30% Timing: first 2 weeks of hospitalization —The first 5 days in critical care unit Highest incidence rate: orthopedic population (9-19%); quadriplegic (33-60%)

6 Morbidities associated with pressure ulcers Pain Disfigurement Septicemia Prolonged hospitalization Increased death rates quality issues

7 Morbidities associated with pressure ulcers- Pain Pain —87% at dressing changes —84% at rest —42% both —18%: pain when CD, the highest level —Only 6% of them received analgesics —Stage III~IV > stage II pain? (some evidence)

8 Morbidities associated with pressure ulcers- Septicemia (I) Most severe complication Incidence 1.7/10,000 Overall mortality 48%: if pressure ulcer is the source Transient bacteremia after debridement: 50% Infectious complication —Wound infection —Cellulitis —Osteomyelitis

9 Morbidities associated with pressure ulcers- Septicemia (II) Among patients with nonhealing or worsening pressure ulcers —26% have underlying bone pathology, osteomyelitis —88% are colonized Pseudomonas aeruginosa —34% with Providencia species —Either pathogen should not be considered typical colonization —Can be reservoirs for antibiotic-resistant bacteria

10 Morbidities associated with pressure ulcers- Death rate Death rate among bed- or chair-bound patients —60% (PU+) vs 38% (PU-) 1 year after discharge Nursing home resident whose pressure ulcers healed within 6 months or not —Mortality: 11%(PU healed) vs. 64%(PU not healed) Mortality rate : 3.8 per 100,000 population —Marker for coexisting morbidity

11 Morbidities associated with pressure ulcers- Q uality issue Pressure ulcer incidence and severity are used as markers of quality care —long-term care facilities —home care agencies —acute care hospitals Evaluate: —Each patient upon admission —Regularly thereafter for high risk group

12 Pathophysiology Pressure ulcers are the result of mechanical injury to the skin and underlying tissues. 4 factors —Pressure —Shearing force —Friction —Moisture

13 Pathophysiology

14 Pressure Perpendicular force or load exerted on a specific area, causing ishcemia and hypoxia of the tissues Muscle and subcutaneous tissues are more sensitive than epidermis High pressure area: —Supine: occiput, sacrum, heels —Sitting: ischial tuberosities —Sidelying: Trochanters

15 Pressure need to impair tissue perfusion Closing pressures — Arteriole - 32 mm Hg — Venule - 15 mm Hg — Capillary pressure - 25 mm Hg > 32 mmHg pressure would cause tissue ischemia

16 Pressure Pressure under bony prominence, ex: —Buttock in lying position: 70mmHg —Sacrum and greater trochanter: 100-150mmHg —In seated persons, ischial tuberosities: 300mmHg Factors lower the threshold —Repeated exposures to pressure —Loss of subcutaneous tissue

17 Shearing forces Lower the amount of pressure required to cause damage to epidermis Decrease the amount of pressure required to occlude blood vessels Tangential forces, ex: sliding Important in development of deep tissue injury

18 Friction and Moisture Friction —Cause intraepidermal blisters —Superficial erosions Moisture —Directly lead to maceration and epidermal injury —Impact on friction forces

19 Assessment Risk assessment Assessment of pressure ulcer stage Assessment of pressure ulcer healing

20 Risk Assessment- Factors Immobility or severely restricted mobility being the most important risk factors —>50 vs <20 movements at night: 0% vs 90% PU occurence Incontinence (Fecal > urine incontinence) Malnutrition Impaired mental status Altered sensation or response to pain and discomfort Increased body temperature Decreased blood pressure Advanced age

21 Risk Assessment - Interval Acute care hospital: —Every 48Hrs Home health setting: —Weekly for 4 weeks, followed by every other week Nursing home resident: —Weekly for 4 weeks, followed by quarterly assessment

22 Risk Assessment – Tool (I) Norton scale —Oldest, developed in 1961, in England —5 subscales: physical condition, mental state, activity, mobility, incontinence, —Each scale 1-4, total score 5-20 —≤16/20: onset of risk —≤12/20: high risk

23 Risk Assessment – Tool (II) Braden scale —Developed in 1987, in USA —6 subscale: sensory perception, moisture, activity, mobility, nutrition, friction and shear —Each scale 1-4, except friction and shear 1-3 —Total score 6-23 —≤16/23: at risk —15-16/23: mild risk, 50~60% risk for stage I PU —12-14/23: moderate risk, 65-90% risk for stage I or II PU —<12: high risk, 90~100% risk for stage II or deeper PU

24 1分1分 2分2分 3分3分 4分4分 分數 感覺知覺程度 ( sensory perception ) 完全昏迷對疼 痛沒有反應 昏迷但對疼痛 有反應 清醒但部分感 官受損 清醒正常 潮濕程度 ( moisture ) 皮膚持續潮濕 皮膚經常潮濕, 更換中單 / 床單 每天≦ 3 次 皮膚偶爾潮濕, 更換中單 / 床單 每天 1 次 乾燥、乾淨 活動力 ( activity ) 臥床不動受限於輪椅 可偶爾下床行 走 可經常下床行 走 移動力 ( mobility ) 完全無法自行 翻身 大部分需他人 協助翻身 少部分需他人 協助翻身 可自行翻身 營養狀態 ( nutrition ) 禁食或進食清 流質 5 天以上 攝取熱量每天 小於 1200 卡 維持管灌可滿 足大部分需求 正常飲食滿足 需求量 摩擦力 / 剪力 ( friction/shear ) 有此問題有潛在的問題沒有明顯問題 總分 /23 註:分數≧ 16 分(低危險): 每日皮膚評估一次。 分數 12~15 分(中等危險):皮膚評估+ 每 2 小時翻身拍背一次。 分數≦ 11 分(高危險): 皮膚評估+ 每 2 小時翻身拍背一次+ 氣墊床使用。 Braden 壓瘡危險因子評估表

25 壓瘡風險評估工具之臨床效度 評估工具 \ 臨床效度 Braden 量表 Norton 量表 Gosnell 量表 Waterlow 量表 敏感度 88.0%86.1%46.3%99.5% 特異性 75.1%75.0%90.9%31.7% 橫斷式之調查法,在台灣地區北部、中部、南部及東部, 各依人口分佈分層抽樣選取 2,631 住院病人為收案對象 。 于博芮、李世代、林壽惠:台灣醫療院所壓瘡風險評估 工具之臨床效度。台灣老年醫學雜誌 2005;1:79-88 。

26 Assessment of Pressure Ulcer Stage Grading or staging system based on observable depth of tissue destruction Initial assessment: deepest layer of tissue involved Mostly common used : —National Pressure Ulcer Advisory Panel’s (NPUAP) classification system —( 美國國家壓瘡諮詢委員會 )

27 Staging NPUAP (National Pressure Ulcer Advisory Panel) 2007 Stage I: Nonblanchable erythema —Intact skin, usually over a bony prominence Stage II: Partial thickness skin loss —Invulving epidermis and/or dermis Stage III: Full thickness skin loss —Extend into subcutaneous tissues to deep fascia, but bone, tendon, or muscle not exposed Stage IV: Full thickness tissure loss —Exposed bone, tendon, or muscle

28 Staging Unstagable/Unclassified: Full thickness skin or tissue loss– depth unknown —Full-thickness injury —Actual depth obscured by slough and/or eschar —Cannot be staged until removed Suspected Deep Tissue Injury– depth unknown —Purple or maroon localized area of discolored intact skin or blood-filled blister —due to damage of underlying soft tissue from pressure and/or shear

29 Assessment of Pressure Ulcer Healing At a minimum: —Location —Depth and Stage —Size —Wound bed description:  necrotic tissue, exudate,  wound edges for undermining and tunneling,  presence or absence of granulation and epithelialization Follow-up assessment: at least weekly Two research-based pressure ulcer assessment tools —Bates-Jensen Wound Assessment Tool [BWAT] —NPUAP’s Pressure Ulcer Scale for Healingtool (PUSH)

30 Reduction in ulcer size over 1-2 week period predict healing outcome Should improvement within 2-4 weeks If no evidence of ulcer improvement  —Consider changes in management strategy Improvement for stage III and IV slower than II —Stage II: 75% healing in 60 days —Stage III or IV: 17% healing in 60 days

31 Management Local treatment Surgery Drugs Nutrition

32 Local treatment Debridement of necrotic tissue Adequate wound cleaning Application of appropriate topical therapy

33 Debridement Wound debridement: —Reduce necrotic tissue burden —Decrease infection risk —Promote granulation tissue formation —NOT indicated for dry eschar on the heel or when the pressure ulcer on an ischemic limb —5 methods of debridement: clinician preference, avalibility Surgical or sharp debridement for extensive necrosis or when obtaining a clean wound bed quickly is important More conservative methods (autolytic and enzymatic) for those in long-term care or home care environments Adequate wound debridement is essential to wound bed preparation and healing.

34 Surgical debridement use of a scalpel, scissors, or other sharp instruments to remove nonviable tissue. most rapid form of debridement indicated over other methods —for removing thick, adherent, and/or large amounts of nonviable tissue —when advancing cellulitis or signs of sepsis

35 Mechanical debridement Use of wet-to-dry dressings, whirlpool, lavage, or wound irrigation. Wet-to-dry gauze dressings continue to be used for debridement Disadvantages: —increased time/labor for application/removal of the dressings, —removing viable tissue as well as nonviable tissue —pain Used cautiously, can traumatize new granulation tissue and epithelial tissue Adequate analgesia should be administered

36 Enzymatic debridement Applying a concentrated, commercially prepared enzyme to the surface of the necrotic tissue aggressively degrade necrosis by digesting devitalized tissue 3 commercially enzymes in USA: collagenase, papain-urea, and papain-urea with chorophyllin Some of the effects attributed to autolysis Debridement faster than with autolysis More conservative than sharp debridement

37 Autolytic debridement Using the body’s own mechanisms to remove nonviable tissue. Maintaining a moist wound environment allows collection of fluid at the wound site, which allows enzymes within the wound fluid to digest necrotic tissue. Adequate wound cleansing to wash out the partially degraded nonviable tissue. More effective than wet-to-dry gauze dressings, —selectively removes only necrotic tissue —protects healthy tissues May be slower to achieve a clean ulcer bed than other methods.

38 Biosurgery The application of maggots (disinfected fly larvae, Phaenicia sericata) to the wound Typically at a density of 5 to 8 per cm 2 May not be acceptable to all patients May not be available in all areas

39 Adequate wound cleaning General rule Pressure ulcer cleaning at changing dressing If an ulcer contains necrotic debris or is infected, then antimicrobial activity is more important. For wounds with large amounts of debris, more vigorous mechanical force and stronger solutions may be used For clean wounds, less force and physiologic solutions such as normal saline should be used.

40 Should not use on clean pressure ulcers : —Povidone-iodine —Iodophor ( 易多碘 ) —Sodium hypochlorite ( 次氯酸鈉 ) —Hydrogen peroxide (H2O2) —Acetic acid Toxic to fibroblast and impair wound healing

41 Topical therapy Using moist wound healing dressings Moist wound healing allows wounds to re- epithelialize up to 40% faster than wounds left open to air These dressings are changed every 3 to 5 days, which allows wound fluid to gather underneath the dressing, facilitating epithelial migration

42 敷料種類 類別舉例 Gauze dressing ( 紗布 ) 紗布 Transparent films dressing ( 透明薄膜 ) Opisite, Tegaderm Hydrogel ( 親水凝膠 ) DuoDerm gel Hydrocolloid dressing ( 親水膠體敷料 ) DuoDerm Alginate dressing ( 藻酸鹽敷料 ) Kaltostat, Seasorb Hydrofiber dressing ( 親水纖維敷料 ) Aquacel, Aquacel Ag Foams dressing ( 海綿型敷料 )PU 泡棉, PVA 泡棉 Composites dressing ( 複合性敷料 )

43 Surgery Primary closure A variety of approaches to skin graft and myocutaneous flap Removal of underlying bony prominence Large infected pressure ulcers: more aggressive procedures ex amputation sometimes required

44 Drugs - Antibiotic Antibiotics —Antibiotics may be systemic or local Systemic antibiotics: —S/S of systemic infection, sepsis or cellulitis with fever and elevated WBC —Osteomyelitis —Prevention of bacterial endocarditis in patients with valvular heart disease —Who require debridement of pressure ulcer Broad-spectrum coverage —GNB, GPC, anaerobes

45 Drugs - Antibiotic Appropriate choices for antibiotic therapy —Unasyn —Imipenem —Meropenem —Timentin —Tazocin —Combination of clindamycin or metronidazole with ciprofloxacin, levofloxacin, or aminoglycosides —Vancomycin for MRSA

46 Drugs - Antibiotic The most effective strategy for preventing infection and dealing with existing infection is adequate debridement of necrotic tissue In patients with S/S of systemic infection and sepsis, the appropriate debridement method is surgical debridement.

47 Drugs - Antibiotic Topical antibiotics (silver sulfadiazine): —For stage III or IV ulcers with evidence of local infection —For clean pressure ulcer not healing after 2-4 weeks of optimal management Prolonged silver release topical dressings: effective in MRSA colonization

48 Drugs - Pain Limited evidence to guide clinician Pressure ulcer alone: may not require routine pain medication Medication prior to procedures is essential Opioids and/or NSAIDs 30 minutes prior to the procedure Topical anesthetics or topical opioids

49 Nutrition Difficult to define a causal relationship between malnutrition and pressure ulcer development Some evidence: nutritional support to persons at risk for pressure ulcers with relative reduction in pressure ulcer incidence of 25% Some evidence: high-protein nutritional supplements (24-25% protein) improves pressure ulcer healing 30 to 35 kcal/kg/d 1.25 to 1.5 g/kg/d of protein

50 Nutrition Nutritional supplementation by tube-feeding to persons with pressure ulcers: not positive results No evidence exists for use of supplemental vitamins or minerals (e.g., vitamin A, E, C, zinc) in persons with pressure ulcers, except for deficiency Persons with pressure ulcer or at risk + malnutrition: Nutritional assessment, nutrition support as indicated Glutamine, Arginine, HMB

51 Prevention Scheduled turning and repositioning programs Pressure reduce/relieve support surfaces General skin care Nutritional support

52 Scheduled turning and repositioning programs Patient at risk, unable to move independently Time interval: every 2 Hrs Avoid pressure on bony prominence, esp malleolus, trochanter: 30-degree side-lying instead of 90-degree side lying Maintain head of bed at lowest degree of elevation: decrease sacral area exposure to shearing force Techniques: Turning sheets, draw sheets, pillows

53 Pressure reduce/relieve support surfaces Static —Foam, gel, static air, water, combination —Less expensive Dynamic —Alternating air( 間歇式氣墊 ), low-air-loss( 低壓氣浮 床墊 ), or air-fluidized( 矽砂床 ) —Use if the status surface is compressed to < 1 inch or high-risk patient has reactive hyperemia on a bony prominence despite use of static support —Adverse effects: dehydration, sensory deprivation, loss of muscle strength, difficulty with mobilization

54 Pressure reduce/relieve support surfaces May reduce frequency of repositioning required in some paitents Relative reduction in incidence of 60%

55 General skin care Skin inspection —Daily, esp attention to bony prominence —Reddened areas should not be massaged Incontinence assessment and management Skin hygiene intervention

56 Reference Hazzard’s Geriatric Medicine and Gerontology, 6th ed. New York: Mc Graw Hill, 2009:703-715 Textbook of Geriatric Medicine International, Souel: Argos, 2010:411-418 NPUAP (National Pressure Ulcer Advisory Panel):

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