From Injuries Pressure and non-healing wounds
There is talk of bedsores or “lesion decubitus or pressure” when determining a tissue lesion in a patient, typically bedridden, where the skin is compressed between the bone and the surface on which lies the body, subjected to a mechanical stress. In these cases, the ischemia of the tissue that results from such compression is due to a tissue injury, with necrotic evolution, which affects the skin, the dermis and subcutaneous layers, until reaching, in very serious cases, the muscles and the bones.
Classifications of bedsores
There are several kinds of sores classification: morphological, clinical and depending on the color, appearance, exudate. Typically, however, the most practical classification followed is that morphological in 4 stages, which are based on the severity of the lesions themselves, if they are recent or inveterate, and on the degree of depth in the tissues.
Stage 1: This is the initial lesions with erythema of intact skin with limited edema. If this first step is done, for example by changing the position of the patient, using a bedsore mattress and taking care of the hygiene tissue and preventing their maceration, then from this stage is passed to the onset of ulcer, particularly if appear pale skin, heat or hardening.
Stage 2: this is characterized by a partial-thickness lesion involving the epidermis and / or dermis. An ulcer that results is superficial and presents clinically as an abrasion (abrasion), a blister or a slight recess.
Stage 3: full thickness wound involving damage or necrosis of subcutaneous tissue with extension until the muscle fascia. The ulcer presents clinically as a deep cavity.
Stage 4: Full thickness lesion with extensive destruction of the skin, tissue necrosis and involvement of muscles, tendons and bones sometimes accompanied by other small ulcers, necrotic all, in various points of support.
Problems associated with the treatment of wounds
One of the most important issues to be taken into account in the treatment of bedsores is represented by infections, all of which slow down the healing process causing edema, purulent exudate also leading to cellular destruction. Moreover, the presence of “black fabric”, necrotic, prevents the repair of wounds because it hampers granulation and promotes the infection. It ‘true that in an attempt to “unleash” the necrotic tissue from the wounds, you run the risk of spreading the infection further, or to affix the additional bacteria injury, including the dangerous Pseudomonas aeruginosa multi-resistant! So watch the curettage of the lesions. Another problem is the increase in local temperature and tissue maceration, especially in summer when the patient wears a diaper and urine and feces penetrate infecting the wound and creating an unhealthy hot and humid “environment”, causing further infection and heating of the lesions with increased metabolism and further increase local tissue ischemia. It goes without saying that some factors intrinsic to the patient are the basis for the perpetuation of pressure sores. Age is responsible for the chronicity of lesions in the elderly because the metabolism is slowed, nutrition is in deficit, the aged skin and thinned and so is the local microcirculation. The immunological response is reduced, the ability of the proliferation and granulation of ulcers slowed. Also the elderly, for our experience, often living in chronic entrapment conditions, for example in terms of fracture of the femoral head, in the course of neurological diseases such as stroke cerebri, for sedation in the course of psychiatric illness and state of psychomotor agitation in patients suffering from dementia and because the subcutaneous adipose tissue and the tissue is poorly vascularized and therefore more vulnerable; the same applies in thin patients, where bone protrusions compress the thinned skin. The senior, finally, is often suffering from chronic disabling diseases such as diabetes, coronary heart disease, cancers, radiation treatments, chemotherapy, hypovitaminosis, states emaciated, anemic, fever, conditions of dysproteinaemia
Approach to pressure ulcers
a) prevention is the first care
b) place the anti-decubitus mattress
c) mobilize the patient every two hours
d) care cleanse, change diapers, to avoid tissue maceration
e) to intervene immediately when the lesion is in the first degree
Patients are followed by Dr. Grassetti in the reference Regional center for the treatment of wounds Difficult at the ‘Hospital of Ancona Towers, assisted by specialist nurses in wound healing. The treating physician will be in the early stages or higher if the pc is not operable, surgical or where necessary for a definitive cure and fast.
In the early stages (first and second):
To free up the wounds from necrotic tissues can be used enzymatic preparations of collagenase responsible for degradation of necrotic tissue. It can be used in order also to specific hydrogel:
• Rehydrate the necrotic tissue
• Dissolve and absorb serous necrosis
• Absorb excess exudate
• To promote the healing of moist wound
In later stages (Third and Fourth advanced):
Surgical therapy for operable patients makes use of modern technique of perforator flaps, recently published by Dr. Grassetti and collaborators on the prestigious American magazine of Plastic Surgery (Perforator flaps in late stage pressure sores treatment: outcome analysis of 11-year-long- experience with 143 patients. Annals of plastic Surgery. 2013 Jun; 12) and presented to the International Society of Plastic Surgery at the European Congress of Plastic Surgery in Turkey in May 2013. it is characterized by the closure of the ulcer after remediation, saving muscles neighbors with double benefit. If on the one hand in fact it avoids the morbidity associated with the sacrifice of a muscle leaving a loading surface no longer protected by a “muscle” cushion, the other will decrease the number of new ulcers to 2 years, the average time of hospitalization and the number of reoperations at 2 years.
The patient is hospitalized the hospital the day before the ‘intervention to careful preparation and anesthesia visit. Dr. Grassetti performs an ultrasound of the perforating vessels and plans the flap to set up the next morning.
The surgery is usually performed under local anesthesia, with the aid of microsurgical instruments and optical magnification and has a duration of about 3 hours.
The post operative recovery takes place in the hospital for 2 or 3 weeks during which the patient rests in a special anti-decubitus mattress Air microspheres not present elsewhere and acquires the rehabilitation information and food needed to avoid recurrences.