Bedsores, sometimes called pressure sores or decubitus ulcers, can develop in people who have been confined to bed for long periods of time, are unable to move for short periods of time, or who use a wheelchair or sit in one spot for long periods of time. Other complications, such as aging, circulation and decreased sensation, can increase the likelihood that a person will develop pressure sores. Hospital patients and nursing home residents, as well as those who are being cared for at home and who are confined to bed are most at risk to develop pressure sores.
These are wounds caused by sustained pressure on certain parts of the body. They used to be called “bed sores” but the new name conveys the cause of these sores to everyone so that they can be prevented. Common sites are the outer side of thigh, lower end of spine (sacrum), heel, and elbow and back of head. In paraplegics on wheelchair, it may form over the ischium (the bone on which one sits). Prolonged heavy pressure for as little as 30 minutes can start a pressure sore. Since pressure on the weight per unit area, it is logical that heavy patients as well as emaciated bony patients (small “bony” area of contact) can get it. It is equally true that all pressure sores are preventable.
WAYS TO PREVENT:
- Identify people at risk.
- Pad all pressure points with designated foam or gel pads.
- Use appropriate mattress / cushion / wheelchair.
- Frequent turning or change of position every hour
- Identify early evidence of pressure (persistent redness in a pressure prone area).
- Keep the skin healthy by keeping it clean, well moisturized and protected.
- Avoid creases / hard areas in bed.
- Avoid skin soaking in urine / faeces.
A plastic surgeon can advise the family on pressure relieving methods, wound care, provide VAC dressings where needed and carry out wound cleaning surgeries. In the bigger cases, skin grafting or flap surgery is required and can be successful. A flap is a segment of skin and deeper tissues that is moved in from nearby areas in order to fill the deep defect and close the wound. The surgical skin defect created by moving the flap can either be closed or can be covered with a thin skin graft. This is okay because the flap donor area is usually not a pressure prone area or it has sufficient padding still.
Several types of flaps are available for complex and deep pressure sores. These can be done even in elderly patients having other complicating diseases.
BLEEDING AND INFECTION:
In order to pinpoint the factors of importance for the improvement of the initial results of surgical closure of pressure sores.
It was concluded that hematomas which are small swellings with blood filled inside them and infection were the main cause of failure. Consequently it was decided to focus on the control of secondary bleeding and infection. Decubital ulcers being contaminated, it is obvious that hematomas which are the small swellings with blood invite infection.
PRE OPERATIVE PRECAUTIONS
Prior to surgery the patient should be in good general condition. If not, a nutritious diet, including supplementary protein, minerals and vitamins, should be provided. The wound should be cleansed daily with soap and water and covered with a large absorbent pad, and changed as required. No dressing material should be put into the wound cavity. From the very beginning of the treatment the patient’s bed should be provided with a water mattress.
First operation: radical excision To control bleeding and infection it is helpful to perform surgery in two stages. The first operation is a radical excision of infected scar tissues. The exposed bone is removed but no major reduction surgeries are done. Antibiotics are given to the patient and patient is asked to turn over on the front side when they are on bed.
Second operation: reconstruction Seven days later the wound will be in the healing phase, ready to receive a vascularised muscle flap which is a portion of skin along wit muscle that has got its own blood supply.
Depending on the location of the defect one of three procedures can be recommended:
1. Ischial sores (Sores located over buttocks)
2. Sacral sores are seen over the bone just above the buttocks
Drainage Following the excision the wounds are left open. Blood and other fluid secretion will be absorbed by gauze that is placed and a bulky dressing, which should be changed before it is soaked through. After the reconstruction, when the defect has been closed, oozing of blood will only be seen from the tissue where the muscle flap has been cut and not from the primary defect. Two suction drains which can remove the fluid from body should be inserted, one under the muscle flap, and one in the secondary defect.
A FINAL WORD FOR THE PATIENTS:
Pressure sores in paraplegic patients that means in patients who are paralysed can be cured by reconstructive surgery as described above. Such treatment usually takes about 6 weeks. It does not protect the patient from developing a similar sore again. Whenever a sore is repaired a thorough investigation should be made not to overlook on the causes and mechanisms of the pressure, and measures should be taken to prevent the patient from exposure to a similar risk in the future.