CHAPTER 22 • MANAGEMENTOF PRESSURE ULCERS AND FUNGATINGWOUNDSFRANK D. FERRIS

Skin is one of the vital human organs. It has a highly developedphysiology and several essential functions in the regulation ofhomeostasis and immunity.

Provides protection. Skin surrounds virtually our entirebodies. It is the outer layer of the structures thathold us intact and give shape to Our bodies. It alsoprovides protection and a cushion when objects hitour bodies.

Senses environment. Skin is highly innervated. It helpssense the environment and avoid injury. When skinis "wounded" and becomes inflamed or infected, theresulting inflammatory response can sensitize noci­ceprors, lead to recruitment of additional neurons,and increase neuronal firing of each involved neuron.Patients frequently experience increasing pain asso­ciated with the wound and the inflamed structures,that is, hyperalgesia and allodynia (1). Although opi­aid receptors are not present in normal skin, withinminutes to hours of inflammation, they may appearin peripheral sensory nerves (2).

Maintains fluid balance. Skin has a highly developedsystem of pores that help to control fluid balance.The pores open and close to regulate evaporationand transcutaneous perspiration.

Controls body temperature. Skin also participates in theregulation of body temperature by releasing fluids onthe surface as perspiration or sweat to evaporate andcool down the body.

. Controls infection. Intact skin presents a physical bar­rier to infections and immunologic barrier to infec­tions. When skin is "wounded," this barrier is brokenand bacteria and other infective agents can colonizeor infect the wound and the surrounding tissuesand sometimes lead to systemic infections or evensepsis. Wound infections can secrete pathogens thatinhibit epithelial cell mitosis and delay granulationand wound healing.

Creates body image. Skin is the most visible organ.Its presence creates a bodily image of who we are.Disfigurement due to wounds may have profoundconsequences on an individual's body image and theway others respond to her/him. If it is bad enough,the patient may want to withdraw, family membersand friends may not want to look at the patient, andhealth care workers may not want to provide care. Ata time when the patient may need more support than

ever, she!he may be abandoned by family membersand caregivers.

Creates body smells. Skin secretes a number of fluidsand substance that have associated smells. Over time,many people develop attractions to each other basedon familiar scents. If those scents change or becomeoverwhelmed by odors from putrefying tissues orinfections, the effect may be repulsive and lead toisolation and abandonment.

There are multiple potential events that can damage skinintegrity and/or function acutely or chronically. For patientswith advanced cancer, particularly the elderly, pressure andfungating tumor masses are the most common causes ofchronic wounds to' the skin and the tissues that lie belowit, that is, subcutaneous fat, muscles, bone, tendons, nerves,blood vessels, and so on.

When patients with cancer experience chronic wounds,not only do they suffer from the underlying cancer and theirwounds, but their whole being is affected by the multiplephysical, psychological, social, spiritual, practical, loss andend-of-life issues that are frequently associated with wounds.To be effective, care of such patients must be consistent withtheir goals of care and treatment priorities, and manage thewhole "wounded" person, not just the "hole" (3,4).

PRESSURE ULCERSPressure or decubitus ulcers are encountered frequently inpatients with cancer, particularly those who are debilitated bytheir illness or by treatment (5,6).

The microarterioles that supply blood to the skin runthrough the subcutaneous fat. In the face of mild pressure, thefat normally cushions and redistributes the pressure. However,when the pressure increases above the capillary filling pressure,the microarterioles close for as long as the pressure is presentand the oxygen tension falls in the downstream tissues. Normalskin can withstand 30-60 minutes of poor perfusion but notlonger. When the pressure and hypoxia are sustained, ischemiaand necrosis can develop relatively rapidly (7,8).

In both general hospital and long-term care, pressure ulcersoccur in up to 28% of patients (9). One study of 980 homehospice patients found that 10% of patients developed ulcersduring the study period (10).

Pressure points, for example, sacrum, heels, and elbows, areat particular risk for the development of ischemia and pressure

239

240 Section I: Symptoms and Syndromes • Part D: Skin

TAll! F 22.1

CONTEXT ASSESSMENT

ulcers. Thin patients with cachexia who lack subcutaneous fatare even more susceptible. When they are weak, fatigued,and unable to move around by themselves, the risk ofdeveloping one or more pressure ulcers is very high. Shear,friction, prolonged presence of moisture associated withincontinence, age-related changes in skin, and poor nutritionfurther compound the risk (11)..

Pressure ulcers most often develop at body sites were thepressure is highest. In supine patients, 60% of pressure ulcersoccur in the sacrum, and the greater trochanter and heelaccount for a further 15%. In patients who are constantlysitting, the ischial tuberosities are more susceptible (4).

MALIGNANT ULCERSMalignant wounds occur in up to 10% of patients withadvanced or metastatic cancer, usually in the last 6 months oflife (12). They can evolve from a primary tumor of skin or aninvasive underlying mass, a recurrence along a surgical sutureline, or a metastasis. They can be both erosive ulcers and/orexpanding nodules. If many nodules confluence, the resultcan be a cauliflower-like wound. They are most commonlyassociated with cancers that start in the breast, particularlywhen they reoccur locally (50% or more). Other common sitesinclude the head and neck (up to 30%) and axilla or groin(approximately 5%) (13-15).

Although a tumor initially stimulates neovascularization, arapidly growing tumor can outstrip its available blood supplyand necrose centrally. When the process involves the skin, itfrequently becomes friable and produces significant exudate;becomes malodorous as the tissue putrefies and/or becomesinfected with anaerobes; and frequently bleeds.

·Issue

O' .•.•.::. :.:'."::: >: :.:., "., ..GaJlce!:"··type,:stage,

pragnasi~

Comorbidities

.Funcd6Iial statUs, farexampl~,KPS, orPPS

~utriti()IialIfluid

status

Cogllitive status

D'ecision-makingcapacity

Medic~tions'that '.'could delay healing

Goals -of tare

Examples·

..:stitge-iy'·b~e~~tcan~¥:~it41?~tast~s~s '.. 'to· liver, lungs, bane; prognosis' ,

1-2mo.. ....".. Rhe:umatoid attliritisAlltoi.tnnlune·disorders, far exampl,e,syst~c lupus; vasculitis

KPS or PPS =50%

A:ppeti~e, for :example, ano,reetic

Degree of ca_cfLeXia, forexaIILP!e,.. 20-lb ;veight loss, albumin 2.1 gldL

. '. Mild deh.ydratic)fi withorthastatichypotension and 1+ pitting ankleedema

AiI';rt, orientedx3,nornialmini-mental status

Has capacity

.Steroids

Nansteroidalanti-in1lammatory drugs'lnununos,uppressive-medicationsMaintain function:MinimizesymptbI!iSInteract clearly with family and friends

ASSESSMENTIn any patient with cancer who has developed a wound, or is atrisk of developing one, start with a comprehensive assessmehtof the patient's illness context, risk of developing a pressureulcer, wound, surrounding skin, blood supply, frequentlyassociated issues, for example, pain, odor, or "woundedness."

lllness Context

Assess the context of the patient's illness, including herlhiscancer type, stage, and prognosis; functional status, for

TABLE 22.2

BRADEN PRESSURE ULCER RISK ASSESSMENT

KPS, Kamofsky;.PPS,; palliativeperfo~ance.st~tus.

example, Karnofsky (KPS) or Palliative Performance Status(PPS); nutritional, fluid, and cognitive status; decision-makingcapaciry; and goals of care (Table 22.1).

Pressure Ulcer Risk

The risk of developing a pressure ulcer increases as can­cer advances, particularly when patients are debilitated (16).

'serisory ..perceptidn

'Moisture ."-

:

Completely limited.

Constantly moi~t, ':',

Bedfast .

Very limited

YeiYmo~st

Chaitfast .

Slightlylimited. .

Occasionallymoi~t

'Walk~-occa~iona1!r' .,

c. Score ":_

Rard);' ,moist

Walks frequently

Mobiliry

, Nuttition.

FriCtion,_ s~~aI'

... :Comptetelyiinmobile

Ptohlem

Very limited

Probablyinadeqmite

;Slightly limited

Adequate , ._

Walks frequently

Excellent ..

,:F16.::: .notatri~~q( ~~veiopirLgpr~ssUre~lcers;; 1~~'1? =~?wrisk;.13"':14 ~.modeiat~risl<;, .:?1~high risk.· '.. . .,

Tatalscore'

Chapter 22: Management of Pressure Ulcers and Fungating Wounds 241

FIGURE 22.1. Wound location. Mark the location of each wound on the body diagrams. Label sites asA,B,C,D.

Periodically assess every patient's risk using either aBraden (17) (http://www.bradenscale.coml) or a Norton (18)risk assessment tool (http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstatl.table.4948). Both tools examine the mostsignificant risk factors for developing a pressure ulcer includ­ing sensory perception, moisture, activity, mobility, nutrition,and friction/shear (Table 22.2, a simplification of the BradenPressure Ulcer Risk Assessment tool-for complete details,refer to the original tool).

Once a wound develops, assess the following:

1. The wound, including the type (etiology), location(Figure 22.1), duration, description of the structureand base/surface, dimensions (best to document witha labeled photograph or diagram (Figure 22.2), exudate,and bleeding (Table 22.3). Observe old dressings forstrikethrough (i.e., drainage on the outside of an olddressing) and then remove the dressing slowly, startingfrom the edges. If dressings adhere to the wound surface,moisten them with normal saline or water to reduceadherence and facilitate removal. If you can anticipatethat there will be pain or if there is any pain during theremoval process, before continuing start on preemptiveanesthesia/analgesia until the patient is comfortable(discussed later in this chapter).

2. The surrounding skin, including contamination, macer­ation, signs of infection, and edema (Table 22.4).

3. The blood supply, particularly in lower extremitywounds (Table 22.5).

4. The frequently associated issues, for example, odor, pain,"woundedness," anxiety, and depression (Table 22.6).

STAGING

Pressure Ulcers

To help determine the management plan, the National PressureUlcer Advisory Panel/Agency for Health Care Policy andResearch (NFUAP/AHCPR) developed a system that is Widelyused to stage pressure ulcers (19).

• Stage 1. The heralding lesion of skin ulceration is non­blanchable erythema of intact skin when compared withanother region of the 1.?ody. In darker skin, the erythemamay appear as persistent blue or purplish discoloration.

• Stage II. Partial-thickness skin loss involving epidermis,dermis, or both. The ulcer is superficial and looks like anabrasion, a shallow crater, or a blister.

• Stage III. Full-thickness skin loss involving subcuta­neous tissue. The ulcer may extend down to, but notthrough, the underlying fascia. The ulcer looks like adeep crater, with or without undermining of adjacenttissue (i.e., skin thatoverhangswound edges).

• Stage IV. The ulcer is deep enough to include necro­sis and damage to underlying muscle, bone, and/or othersupporting structures such as the tendon or joint capsule.

I 242

Feet

A

Section I: Symptoms and Syndromes • Part D: Skin

Bl- .....I

Stage III pressure ulcer8 em long x 5 em wide

Feet

Non blanching !·J~t~~~._.•erythema 0" _ . -0.-,. ".

~ .Dermal

breakdownstage II

Tunnelingupto10cm

Head

FIGURE 22.2. Description of a sacral pressure ulcer. Pho­tograph or. trace the circumference of the wound and anydamage to surrounding skin onto a transparency or plas­tic page protector, including areas of tracking or tunneling(indicating measurements, usually in centimeters). Use plas­tic wrap next to the skin to avoid bacterial or body fluidcontamination.

Undermining of adjacent skin and sinus tracts or fistulamay also be present.

• Stage X. DnstageabIe, depth unknown

Malignant WoundsThere is no specific staging system for malignant wounds.

MANAGEMENTIf patients who are at risk of developing a pressure ulcer, orthose who are in the process of developing one, are caughtearly and appropriate prevention and treatment initiated, pro­gression can be arrested and significant morbidity preempted.

lnterdisciplUrraryWound care always involves an interdisciplinary team thatincludes a nurse and physician at a minimum, and may includean enterostomal therapist who is an expert in wound care, apharmacist, a social worker, a chaplain, a physiotherapist, adietitian, and so on, especially when the patient's issues aremore complex.

Establish Goals of CareTo develop an effective plan of care, start with effectivecommunication with the patient or her/his surrogate decision

maker about the context of the patient's illness, the patient'spersonal goals of care, and possible therapeutic optionsincluding their benefits and risks of harm and burden. Carefullyguide a decision-making and treatment-planning process thatinvolves the patient, herlhis family, and caregivers.

For patients with pressure ulcers, if the blood supply tothe surrounding tissues is adequate (i.e., Dorsalis pedis and/orposterior tibial pulses are palpable or ankle brachial index(ABI) >0.5 or toe arterial pressure >40 mm Hg), it may bepossible to heal the wound. For many patients- with advancedcancer and a short prognosis, it is unrealistic to strive to heal apressure ulcer. For such patients, it is much more appropriateto focus on stabilizing the wound, relieving interface pressureto prevent further progression, and managing associatedsymptoms.

For patients with malignant wounds, if it is not possible totreat the underlying cancer, it will not be possible to heal amalignant wound.

PRESSURE ULCERS-WHEN THEGOAL IS TO HEAL

When the goal is to heal a pressure ulcer, management involvesconventional wound care strategies (20).

1. Start by reducing the interface pressure.2. Then prepare the wound bed. Cleanse, debride when

there is necrotic tissue or slough with preemptiveanaesthesia/analgesia, and control infection and bleed­ing (21-24).

TABLE 22.3

WOUND ASSESSMENT

Examples

Chapter 22: Management of Pressure Ulcers and Fungating Wounds 243 •

Type of wound (etiology)

LocationDurationDescription.ofpressure ulcer

D~scription ofnialignantfungating wound

Base/surface

Dimensions (Figure 22.1)

Exudate

BleedingStrikethrough, that is, .drainage

on the outside of an- olddressing

Pressure, malignant cavitating or fungating, chemotherapy extravasation; radiation reaction",dial?etic,.neurotrophic, arrerial,ven9uS, acute surgic~, acute-tr~uma

Precise la<::ation, ideally placing die wound on a body diagram (Figure 22.1)How.long the patient has had itNonblanching erythema of dermis,.no breakdown or disruption of epidertnisDermal breakdownCavity with breakdown extending to subcutaneous fat, muscle, boneNodular, cauliflo~er, cavitatingPercent necrosisColor, for example, black if eschar, red if granulatioh·tissue, or yellow if fibrous tissue or

slough .Friability~ for exarnple, -tissue breaking dowJl on 'C()ntactExposed structures, fbrexample, tend~n, nerve:, major bl?od vesselGreatest vertical (head. to toe) and horizontal dimensions· at right ariglesGreatest depthof open wound using a probe, or height of a raised fungating woundDepth of any tracks (e.g., overhanging skin) or tunnels that extend underneath the skin

through soft tissue and either dead end {e.g., !iinustraces} or open onto the skin in anotherlocation (e.g., fistula)

Color, for example, serous, sanguineous, serosanguineous_Purulence

Volume, for example,none, mild, moderate, copiousOozing or frank bleedingColor,Jor example; serous, sanguinous,-serosanguineousPurulenceVolume, for example, spotting, soaked

3. Once the wound bed has been prepared, dress thewound to promote moist interactive wound healing. Ifthere is a risk of significant shearing, tearing, or regularcontamination with exudate, urine or stool that couldcause maceration, protect surrounding skin.

4. Pack all dead spaces to keep them open and draining.5. Layer dressings.6. Finally, manage all associated issues, including pain,

odors, and the patient's "woundedness."

Reduce Interface Pressure

Continuous pressure, particularly over bony prominences,increases the risk of ischemia, skin breakdown, and pain (11).Pressure ulcers can develop within hours if the patient is notmoved and circulation remains compromised.

Pressure at an interface is the force per unit area that actsperpendicularly between the body and the support surface.This parameter. is affected by the stiffness of the supportsurface, the composition of the body tissue, and the geometryof the body being supported (16).

• Pressure reduction is a therapeutic strategy to reduce theinterface pressure, not necessarily below capillary-closingpressure.

• Pressure relief is a therapeutic strategy to reducethe interface pressure below capillary-closing pressure(25,26).

In patients with advanced cancer, particularly those whoare debilitated, and patients with wounds, implement as manystrategies to reduce, if not relieve, the interface pressure asmuch as possible, including repositioning, turning, massaging,supporting, protecting, and avoiding rolling and bunching ofbedsheets and dressings.

Position

To minimize sacral pressure in patients who are bedridden,keep the head of the bed as low as possible, ideally at <30degrees. Raise it only for short periods of social interactionor use foam wedges to support the patient. Avoid resting onelimb on another. Use a pillow or another cushioning support tokeep legs apart. Protect bony prominences with hydrocolloiddressings.

TABLE 22.4

SURROUNDING SKIN ASSESSMENT

ContaminationMaceration due to

excess moisrureSigns of infectionEdema

Urine, stoolWhite hyperkeratosisWet-surfaceErythema, wannth,tendernessType, for example, pitti-r-g,nonpittingVolume, for eX<Hnple~mild, moderate,

severe

TumWhen a patient is unable to move by herself/himself, turn thepatient from side to side every 1 to 1.5 hour. In addition toreducing pressure, this helps to relieve joint position fatiguein immobilized patients. Use a careful "log-roll" technique todistribute forces evenly aCross the patient's body and minimizepain on movement. Use a draw sheet to reduce shearing forcesthat could lead to skin tears. If turning is painful, turn thepatient less frequently and/or place the patient on a pressure­reducing surface, for example, air mattress or airbed. Aspatients approach death, the need for turning lessens as therisk of skin breakdown becomes less important.

TABLE 22.,

BLOOD SUPPLY ASSESSMENT OF EXIREMITIES

>40irim Hg indicates adequate~pe~sion

Transcutaneous partial oxygensaturation ..-

Toe: arterl~l' pl:"eSSUres(photoplethysmogral'hy)

,.",_ .., , "., _.""-"",--

:" Dp~salis pecli~;-6,I:I):osteri~r::t-ibi&l IfpalpalJIe, s~s_t6liGPIessUrei~-~-- 8:o._rriihHg-~i-~~~t~r;and'p_eifu~i-b~ i~ adeqtla" to facilitate'' .. -,pulse~,;>--:.--:-:-: c, ",":--..::.... .. ::' healihg.-':\'-: ", ;'~,'-'< ,"-:-: --'_:', '_,.':,'")-, .. _,',-,,';, ,.' ;-.,' :.'-':: ,", -'.' --~ c

Doppler ABt=imkle~ystolic', .. 'A:!31°'" Toe-~~al:pressllre- Risk Qfno't.h~aling--l?ressu~e/brachial systolic '>0.8 5S mmHg l:ow" _ _'pressure.F7) (e.g."80 thm>O.6 ->40-mmHg Moderate (adequate perfusion)

. Hg/IOO rom Hg = 0.8) >0.4 >20 rom Hg High (inadequate perfusion)<0.4 <~Omm-Hg- Severe -

>3P% indicates adequate' perfusion

, ,

ABI,ankle brachial indeX;

Odor

Massage

Massage intermittently to stimulate circulation, shift edema,spread out moisturizing lotions, and provide comfort. Thisis particularly helpful in dependent areas subject to increasedpressure, before and after turning. Avoid massaging skin thatis erythematous or broken down.

Support

Therapeutic support surfaces that reduce or relieve pressureinclude specialty mattresseslbeds, chairs, wheelchairs,· andpositioning devices.

Foam Pads

Simple foam pads are often ineffective. If they are used, theymay need to be layered so that they are at least 6-8 inchesthick. If the pressure has been reduced adequately, when ahand is placed under a pad at the lowest point of the patient'sbody, for example, under buttocks, there will be at least 1 inchof noncompressed foam between the hand and' the patient.

Three groups of mattresseslbeds have demonstrated effi­cacy:

• Group 1. Air or ~ater mattress overlays reduce pres­sure. If einployed' early enough in any patient who is

TABLE 22.6

ASSOCIATED ISSUES

Frtiiiy'()rfmil:§melling]usturider,c#~s.sirlgor.throughout'theroom:'

,Pain{de~c~ibe" ,:J:,;qcat!oD.,': •.,... ,...... .c.';.' :',c", ',' ,/:<" ',,;.for each .- . Type,. for'example;:nociceptive,neUropathi~~,maj'ar site) ;' h'iixed:" __ ,, " "':".' ,-

_Temporal profile,' for'eJ(ample,' C9ri~tant,~re~~thr()llgh, intermitteni:'ac}lte'­

:.s~verity, ~or' ~aniple, 3/10·on a yisua-l analog, scale. "

"Effect ofme'dications,(benefit(1ildadverseeffects,:e.g.,drowsmess, nausea,c:()nstipa~onL, '

Anxiety See Chapter 40pepression S'eeCh~pt~~40

, "WO,uTIdJ;I.¢SS'" Psyc~ological sta.te~Bodfimage

bed-bound, has limited mobility, or is cachectic, they willhelp prevent pressure ulcers.

• Group 2. Low-air-loss beds are used for any patient whois at high risk of developing a pressure ulcer, or for apatient who has developed an ulcer already and the goalis to prevent worsening and/or promote healing.

• Group 3. Air-fluidized beds are reserved for patientswho need pressure relief. However, patients frequentlydescribe them as overly confining (even "coffin-like").They are also very expensive.

Cushious

For chairs and wheelchairs, there are a number of pressure­reducing cushions. For chairfast patients who need to usea chair or a wheelchair for a prolonged time, it may bemore effective to have them assessed professionally for cus­tomized pressure-reducing cushions. Never use round cushionscommonly called donuts. They redistribute pressure withoutrelieving it.

Protect

Protect thin, fragile skin from friction, moisture, and shear tominimize the risk of skin tears. This is particularly importantin cachectic patients who have lost the elasticity and resilienceeffect previously provided by their collagen and subcutaneousfat. Thin films will reduce shearing forces. Hydrocolloiddressings will add a cushioning effect.

Caution

Be sure that bedsheets do not wrinkle and dressings do notripple under the patient, as both will produce new pressurepoints that could lead to ulceration if sustained, particularlyin patients with cachexia.

Cleanse

Prepare the wound bed by cleansing and rinsing away exudate,slough, and debris. Although it may be acceptable to userelatively cytotoxic fluids to clean intact skin, for example,hydrogen peroxide, povidone iodine, or sodium hypochlorite,avoid using them in the wound. Although they decreasebacterial burden, they will be cytotoxic to granulation tissueand delay healing (28).

When choosing a wound cleanser, a useful rule of thumbis: "don't put anything into the wound that you wouldn't putinto your eye." Unpreserved normal (physiologic) saline or

Chapter 22: Management of Pressure Ulcers and Fungating Wounds 245 _

sterile water are the preferred wound cleansers. Although bothcan be purchased commercially, saline can also be preparedon the stove-top at home. Mix two teaspoons (10 mL) salt infour cups (1 qt or L) water; boil on the stove 3-20 minutes;cool to room temperature; do not store more than 24 hours.Alternately, use a commercially available wound cleanser withas little cytotoxicity as possible.

Cleanse the wound gently to avoid flushing away migratingepithelial cells or damaging normal tissues using one of thefollowing four techniques:

1. Soak or compress the wound with a saline-moistenedgauze.

2. Gently pour the cleanser over the wound.3. Irrigate the wound with a piston or bulb syringe that

delivers 5-8 pounds per square inch (PSI) pressure or, toremove slough or eschar, irrigate with an 18-20 gaugeAngiocath on a 30-60 mL syringe held 4-6 inches fromthe wound, which delivers 5-15 PSI pressure.

4. Use a commercial spray wound cleanser with a predeter­mined PSI pressure. If there is any pain, stop cleansing,start on preemptive anaesthesia/analgesia until the pa­tient is comfortable, and then continue cleansing.

Maintain good hygiene on surrounding skin using unpre­served normal saline or sterile water, or with a more cytotoxicfluid or commercially available skin cleanser.

Debride

Necrotic tissue (eschar or slough) and contaminated and for­eign material can delay wound healing and harbor infections.Optimal wound healing will not occur until these are removed.If there is significant necrotic tissue or slough, and the bloodsupply to the surround tissue is adequate for healing to occur,that is, ABI >0.5, after cleansing the wound to remove de­bris, debride as much of the necrotic and contaminated tissueas possible and expose dead spaces. Where possible, debridedown to a bleeding base. This converts a chronic wound intoan acute wound and decreases surface bacterial burden.

Choose from the available debridement techniques, forexample, surgicalfsharp, autolytic, enzymatic/chemical, me­chanical, or larva~ on the basis of a thorough assessment of·wound and the goals of care for the patient (Table 22.7). Ifthere is associated gangrene, delay debridement until a lineof demarcation between healthy and necrotic tissue develops.Avoid blood vessels, nerves, tendons, or other underlying struc­tures. If using surgical or mechanical debridement, instigatepreemptive anaesthesia/analgesia beforehand.

Control Infection

All wounds are colonized by bacteria, fungi, and other infectiveagents, but this does not mean they are infected. Staphylococcusepidermis and Corynebacterium are the most common coloniz­ers of wounds. Proteus, Klebsiella, Pseudomonas, and Candidacommonly infect wounds, particularly when there is recurringcontamination with urine or feces or immunocompromise.

If present in sufficient quantities, the wound and thesurrounding tissue may become infected. Healing can bedelayed significantly. Purulent exudates, pain andlor foul odorsmay be the first signs of local infection. If the odor is fruity andthe wound has a greenish tinge, the wound is likely infectedwith pseudomonal organisms. If the odor is foul/putrid, it islikely infected with anaerobic bacteria.

If the goal is to heal the wound, establishing when a woundhas become infected to the point that the bacterial burden

-impacts healing can be difficult. A careful swab technique to

obtain meaningful samples is most important to gain useful cul­tures. First, cleanse the wound with normal saline or water andremove all debris. Then swab healthy-appearing granulationtissue in a zigzag pattern, gently rotating the tip of the swab. Ifthe wound is dry, premoisten the tip of the swab with a littleculture media. If, .after culturing swab samples, the cause re­mains elusive, consider culturing a biopsy from the wound bed.

If the infection is superficial, cleanse the wound with salineor water and apply a topical antibiotic with each change ofdressing (Table 22.8) (33). If there is infection in the surround­ing tissues, or if wound healing is delayed, add a systemicantibiotic until the infection is cleared. If there is obvious can­didal growth or a lot of crusting, mix a topical antifungal, forexample, ketoconazole, with the topical antibiotic or alternatethem. If the ulcer probes to bone, suspect osteomyelitis andconsider 4-6 weeks of systemic antibiotics.

Honey and yogurt may also be very effective topical antibac­terials, even when they are diluted (34). Use only honey tharhasbeen irradiated to ensure that it is free of clostridium spores.

Control Bleeding

Bleeding is much more of a problem in malignant wounds thanin pressure ulcers. If dressings adhere to the wound surface,moisten the dressing with normal saline or water to reduce ad­herence and facilitate removal. If uncontrolled bleeding occursin a pressure ulcer, management strategies are the same as thosefor malignant wounds (see section on "Malignant Wounds").

Dress the Wound and Surrounding Tissue

This section aims to present the principles and suggest astrategy for dressing chronic wounds, not recommend specificdressings. Any reference to commercial products is only toillustrate a point, not to recommend particular products.Contact manufacturers for detailed information about theirproducts and how to use them.

If healing is the goal of pressure ulcer management, theepithelial cells and fibroblasts that must proliferate to formgranulation tissue and fill in the wound require a moistenvironment that is rich in oxygen and the nutrients necessaryto sustain their replication and migration. At the same time,the environment must protect the wound, control excessiveexudate, and minimize exposure to infective microorganismsthat can inhibit healing. By contrast, a dry environment isconducive to necrosis and eschar, and not to healing.

There are seven classes of dressing: foams, alginates,hydrogels, hydrocolloids, films, gauze, and nonstick dressings(Table 22.9). They are distinguished by their absorbency, weartime, and occlusiveness. Within each class" specific productsalso vary by size, user friendliness, cosrJaccessibility, adhesiveused, and impact on the wound margin and surrounding skin.As studies of different types of moist wound dressings showedno difference in pressure ulcer healing outcomes, use clinicaljudgment to select a type of dressing most appropriate for agiven wound (35,36).

To hold dressings in place, there are a wide range of tapesand stocking products that use varying adhesives and mayresult in different hypersensitivity reactions.

Dressing Strategy

If healing is the goal, use a dressing strategy that enables thefollowing:

1. Keep the wound bed continuously moist. A dry woundneeds to have moisture given to it through a hyp atonicgel (donates water). If there is excessive wet exudates, a

I 246 Section I: Symptoms and Syndromes • Part D: Skin

TABLE 22.7; • ",.c T' '> ~,"' , ~

DEBRIDEMENT TECHNIQUES

Technique ~

SurgicaJIsharp

Autolytic

Enzyi:itidc~emical

'<Usellf''~~ed sciss~rs;;.~uieri~,~::orscaJpd.

Use.o.fmoistinteract1.vedressings (e.g., hydrogels,

:hycliocolloids, alginaies,filfgs) .,:' to liquefy n~crotic tissue. ~.... ..- '" .';-' ,", .

- ;:.... . ...•-_... '<..... ':':', - "".i ,',- _ ._

:Us'e ofcollagellase or papatnfo,'diges~ damaged collagen, butriot newly formed granulationtissue.

iriigatiorito,rern.ove nec"rotic tissue. Use all.,1,8~20gauge'~giO~~tKOil :a30-60 mL syriuge ro keep:~pressureundeJ;lS ~SI.:,

Use Oflarvae to conswne"necrotic, tissue (30~3~I'

, -Precautions

Make-sure there is adequate'blood supply for healingto'occur: ABI >0.5

,'Toepress~e'>40 mmHgTranscutaneous oxygen,sa~ation >30%.

';

Remove'asmuch loose'd~bris a~pc)ssible-.when

.&angingdressing~(usually q24-48 hinitially). . .

Bacterial infection aridbacteremia can:occur.Detergents, ble~ch, .hexachlorophene, andheavy metals (e.g., silver,mercury) may inactiyateeIlzymes.

, Excessive f()rce rn~y flush'away migrating'epithelial' ­cellsordaITLage normal_tissu~. '

Use'larvae:cwtured:£or'rruspurpose.

-Encloset4em'within thewound. Monitor tlierr,·aCtivityC:losely.Rem6v~them 'when the" ,,_,'" ',':,debddeIQ.ent i~cQmpi~te.

q:>IumfEots

Fastest:;, most e£fe~ve' techiiique forhuge areas of necrosis" a high 'degree,of contamination or frank infection.

Requires a skilled clinician.Manageprocedriralpain withpreeriiptive--anaesthesia(e.g., topicallidocaine .cream or' sptay, ;EMLA}.Gendest technique. Results, should be

,seen within 72h.Occlusive dressingsfacilitate ati1:o1y~is

iJy maintaining a moist emrironment.,Mollitorfo~oyeihydrationand"¥ecttol1.,, ",':, ,.Faster thaIlautolytic debridement (29).

'To facilitate the process, scoreescha~ without causing bleeding.

Do not use on normal or granulationtissue. Enzymes do not facilitate diegranulation and reNepithelialization·phasesof woUnd care. They maydamagenormal.tissues.Saline wet~to-drygauze, dressings,'

irrigatiOJ,1,'~nd whirlpool therapy arealterna~eine.chanicaldebridingtechniques. rhelatt~r is notrecommended as it may, cause pa!D0:'= ble~dingand'da~age'normal or,'granulation tissue that,sticks to thedry gauze when the dressing isremoved.

Relatively rapid techIJique" to, debridelarge,',volumes of necrotic tissue.

May be Offensive to,patients, families,or staff.

hypertonic gel, alginate, or foam will remove fluids fromthe wound.

2. Control exudate. This should be done without desiccat­ing the wound bed. Wound exudates can be substantial,especially from stage N pressure ulcers and malignantwounds. When there are copious exudates, consideruncontrolled edema or' increased bacterial burden orinfection as possible causes (37).Both foams andalginates can absorb' fluids that are manytimes heavier and effectively remove copious exudatesfrom the environment of the wound.. By wicking theexudate away from the wound and surrounding skin,the risk of infection and maceration is minimized. Bycontaining the fluid within the dressing, it will notdrip onto clothes and bedsheets and it will be morecosmetically pleasing for everyone. Change dressingsonce strikethrough is present, that is, leakage throughto the outside of the dressing.

3. Keep surrounding skin dry. In addition to cleansingsurrounding skin, zinc oxide Or barrier creams or sprays

may help protect the skin from prolonged contact orcontamination with fluids, for example, exudates, urine,or feces. Some sprays may also increase adherence ofadjacent dressing. When the risk is expected to beongoing, thin film or hydrocolloid dressings placedaround the wound with a cutout for the wound dressingscan provide furrher protection (38).

4. Eliminate dead space. Loosely fill all cavities withnonadherent dressing materials, for example, alginatesor hydrogel~soakgauze.

S. Consider caregiver time, skill, and burden. Wound carecan be burdensome. Do not create a plan that is notphysically or financially possible for the parienr andcaregivers to adhere to.

6. Monitor dressings applied near the anus. Dre~sings closeto the anus/perineum tend to move and bunch upunder the tremendous friction and shearing forces inthe sacral area.

7. Dress in layers. As no single dressing will meet all thesecriteria, use a layered approach for dressing a wound.

Chapter 22: Management of Pressure Ulcers and Fungating Wounds 247 •

TABLE 22.8",., ~ "'""-~-~'~-" - -~"-'--~"-""~'"""~

COMMON TOPICAL ANTIBACTERIAL AGENTS

Stapbjilococcusaureus ~SA StreptocOCCUs" Pseu.d.omonas: Anaei"obeS' Comments

Cadexomeriodfne'4re~sing~

~':i6nizedsilver-dre~s~gs

pusidicacid-creari1/ointinent

Gentamicin ­,crearnlointm~nt

Metropjdazolegel/cream

PolymyxinBsulfate~Bacitiacm

zmc'PolymyxinB

sulfate-Baci.ti:aclp.zinc-neomyCin

Silver, sulfadiazine

..;

..;

..; ..;

..; ..; ..; ..;

..; ..; ..; ..;

..;

Microsphetes of starchcross~liriked with ether,bridges, and iodine

Absorbs up to seven times itsweight m.'inoistureSlowly releases iodme forantibacterial action withouti:>eing cytotoxic to ,epith.elialcellsCaution :with thyroid disease,iodine allergySlowly xeleasessilv~r

De.l:reases surface£dabilityMust be iIsed with sterilewater,not,salme (whichprecipitates the silver asmactive silver chloride)Lanolin in ointment,base

may "act a~a sensitizer;

Good.peIietiationandwound deodorizer

Broad spectrum;' loW- cost

Neomycinis a potentsensitizer; maycross:'sensitize to'otheraminoglycosides

Do not use in sulfa-sensitiveindividuals

,',MRSA, methicilluHesisrimt Staphylococcus'aureus;V,rise.

The primary or first layer goes next to the surface of thewound. It can include a hydrogel, an antibiotic, and/orthromboplastin. Subsequent layers rest one on top of theother. Finally, the top or outer layer typically holds the

. dressing in place and serves as the "aesthetic" covering.There is no minimum or- maximum number of layers.Build the best possible combination for the patient'ssitua,tion on the basis of your clinical judgment.

Although dressing changes may be initially needed onceor even twice daily to control infections and remove copiousexudate, as the exudate and, infection settle and the woundstabilizes, the frequency of dressing changes may be reduced(even to once or twice per week).

Examples

The dressing of stages I-IV pressure ulcers varies considerably.The following examples illustrate the range of strategies thatare possible:

Stage I and II Pressure Ulcers. Dry stage I and II pressureulcers are typically dressed with a transparent film placeddirectly on the surface of the wound to protect it fromcontact or irritation. It forms a semiocclusive barrier tothe environment. A film dressing is typically· changed every3-5 days (39). Exercise caution when removing it. A strong

adhesive can easily lead to tearing of fragile skin. If youare having difficulties removing the dressing, use an adhesiveremover to facilitate the process.

When there is limited' exudate, a hydrocolloid placeddirectly on the wound will more effectively absorb the exudate.It forms an occlusive barrier and a moist internal environmentto facilitate autolysis and healing. If there is mild necrosis, usea two-layered approach:

1. Primary dressing (next to the wound). Apply hydrogelto stimulate autolysis.

2. Second dressing. Place a hydrocolloid to form anocclusive barrier and facilitate autolysis and healing.

Hydrocolloid dressings are typically changed every 3-7 daysor sooner if leakage occurs. Exercise caution when removingthem. Their strong adhesive can easily lead to tearing of fragileskin. If you are having difficulties removing ,the dressing, usean adhesive remover to facilitate the process.

Stage ill and IV Pressure Ulcers. Stage ill and IV pressureulcers are often much more complex to dress, depending ontheir configuration and the involvement of surrounding tissues.As an example, for a newly diagnosed dry stage IV pressureulcer with tunneling that is infected, has a foul odor, and

I 248 Section I: Symptoms and Syndromes • Part D: Skin

TABLE 22.9- . ~ ,

DRESSINGS

Class· Absorbency _Weartinte Types :Cor:nmenis

Facilitat~nonadherence

,-','" .. '.-". ,'-,' .-- .,.. '-,"-

Ide~forcopiousexuda:te

MaYrn3cerate surrounding' sJ?n.Either pr()tect the surrounding skin

with-p~trolatwn.orzincoxideointment, or cut the.f0aIIl to theinside dunensions of the woundimd- wick the exudate to setondarydressings.

Seaweed-derivativeHemostatic ,.

R(lp~ ~icks vertically.. :ideal forpackillg,'tracksaq.d tunnelsG?nY~rt to gel on,contact with £lui_d;can wash off in the shower;Facilitate auto'tytic debridementUse tohydrate

Sheets,ribbons,.or ropes

PetroleUiTI-coa.ted pads"inertpads,' inert'!Uesh

Pads; tapes,!1ets

.Bothadheslve and, n'onadhesive,films

'Several differentbases used indiffereiltproducts~forexaLtlple,hydrocolloid, propylene glycol,sodium chloride

Millinieter thick pads consisting Facilitate autolytic debridementof a meri1_brane or other Proted; b6tiy prom.i..J:1ences and areasbacking with a hydrophili<; .. of potential skin breakdoi,ynlayer (e.g., gelatin, pec~} and'a O'cclusivebarrier for fluids (e.g;,hydropilObic layet(e;g.,.. tirinei feces} andfC?rsho'wering andcarboxylnethylcellulose) .' swi~g .' , _

Gelatin layer liqtlefiespncontact O~casionalallergies to adhesiveswilli fluids~.minimizing traUma ()D. Must avoid leakage channels, whichremoval can introduce bacteria, a~d, rippling,

. Usually self-adhesive' whichcariresult in new pressurepoints 'Prote.ct£i;agile skin from shearing md

tearingPefniit'visualizatioilO~ge:D.'permeableFacilitate're,:epitheliaIization

-Avoid)eakage:channels, which canintroduce bacteria"B~rierJorshowering and'swimIning:Idealouterdressings -_.Hold, dressing in placeCosmetic

12-48 .or,morehours

24--48 h fordebridement

3-7 dforp;rote:ction

24--72h

Up to id

"Variable,depel1dmg.onstrikethrollgh

Upt07 dUp to 7 d

... 24h-7 d

Variable,.depending onthe tonicity ofthe gel

Minimal 1-2+/4

3+/4

None

NODe

Variable 1-2+/4

4+/4

4. Hydrocolloids

3. Hydrogels

2. Alginates

6. Gauze

7. Nonstick

:-5. Transparentfilms/membranes

is somewhat friable and ooz~g blood, use a four-layeredapproach:

1. Primary layer (next to the wound). Isotonic hydrogelwith an antimicrobial against anaerobes, for example,metronidazole.

2. Second layer. Alginate for its bacteriostatic properties,ease of conforming to the structure of the 'Wound andtendency to turn to gel on contact with fluids, therebyminimizing trauma to the wound surface and washingoff easily.

3. Third layer. Cotton gauze or an abdominal pad tocontain and protect the underlying dressing.

4. Fourth (outer) layer. Tape to hold the outer dressinglayer in place.

For a particularly friable, bleeding wound, the layeringmight start with an inert nonadherent mesh dressing placed onthe surface of the wound to protect the surface from traumaduring repeated dressing changes.

Adjuvant Therapies

In addition to standard wound preparation and dressingstrategies, for more challenging wounds, there are a number ofadjunctive therapies that could help stimulate the granulationprocess, for example, vacuum-assisted closure {YAel therapy(see http://www.kci1.coml35.asp.). warm-up therapy, andelectro stimulation. You can read more about these therapiesonline, or in Krasner's Chronic Wound Care ill textbook (4).

Chapter 22: Management of Pressure Ulcers and Fungating Wounds 249 •

PRESSURE ULCERS-WHEN THEGOAL IS TO STABILIZE

When the goal is not to heal a pressure ulcer, the plan of careis based on the assessment of the wound and the surroundingtissues.

Assess and stage the pressure ulcer as discussed earlier ~

Management

Reduce Interface Pressure

Always reduce_ the interface pressure using the techniquesdescribed earlier. This will minimize the risk of furtherprogression of the existing pressure ulcers, and reduce therisk that new ulcers will develop.

Cleanse, Debride, Dress

Dry Wounds. If the wound is covered with a dry eschar andthere is no sign of pain, odor, or infection in the wound, theeschar Or the surrounding tissues, leave the wound alone. Thedry eschar may be the most effective barrier against infections.Cleansing or debriding will only soften and ultimately removethe eschar, exposing the underlying tissues to an increased riskof infection and creating the need for routine dressing changes.To reduce bacterial burden, intermittently paint the eschar andthe surrounding tissues with an aseptic iodine solution and letit air-dry. While it is contraindicated for healing wounds, thecytotoxicity of iodine can minimize the risk of infection and theneed for a more complex wound management strategy (22).

If the wound needs to be covered to protect it, or foraesthetic reasons, cover it with a nonstick, nonocclusivedressing.

Wet Wound. If the wound is open, wet, or infected inthe wound bed or surrounding tissues, pursue a cons,ervativewound management strategy to stabilize the wound, controlinfection; exudate, odors and bleeding, and maintain the bestpossible body image.

MALIGNANT WOUNDSThe management of malignant wounds is basicaliy the sameas for advanced pressure ulcers (12-15,40,41).

For some patients, antineoplastic treatments may offersignificant palliation of the symptoms associated with amalignant wound. Radiation therapy may decrease bleeding,pain, and exudate. Chemotherapy or hormonal therapy mayeven promote wound healing in patients with responsivedisease.

Assessment, Staging

Use the same assessment tool (Table 22.1). There is no specificstaging system for malignant wounds.

Management

Establish Goals of Care

Ensure that everyone is clear about the goals of care. If thereexists chemotherapy or radiation therapy that could treat theunderlying cancer and cause it to shrink or disappear, it maybe possible to heal the malignant wound. Otherwise, if thereis no effective therapy for the underlying disease, there will be

no possibility for the wound to heal. Focus goals on stabilizingthe wound, controlling infection, exudate, odors and bleeding,and maintaining the best possible body image.

Reduce Interface Pressure

To minimize the risk of. developing or extending any pres­sure ulcers, particularly in cachectic, debilitated patients withcancer who are chairfast or bedridden, reduce the interfacepressure as much as possible by repositioning, turning, mas­saging, supporting on pressure-reducing surfaces, protecting,and avoiding rolling and bunching of bedsheets and dressingsas outlined earlier.

Cleanse

To remove necrotic debris and exudate, flush gently withnormal saline or water at low pressures, as underlying necrotictissue may be friable and bleed easily. Avoid cytotoxic woundcleansers.

Maintain good hygiene on surrounding skin using unpre­served normal saline or sterile water, or with a more cytotoxicfluid or commercially available skin cleanser.

Debride

Debride using autolysis or a very gentle surgicaVsharptechnique. Cautiously remove as much of the putrefyingnecrotic tissue that may be infected as possible, particularly ifthere is an associated foul odor. Use caution when approachingthe tumor surface that may be friable, painful, and bleed easily,particularly if there is a lot of neovascularization close to thesurface.

Control Infection

Most frequently, anaerobes' infect the necrotic tissues andslough associated with a malignant wound and produce afouVputrid odor and a purulent exudate. If the infection issuperficial, cleanse the wound with normal saline or water,debride cautiously, and apply a topical antibiotic with eachdressing change (Table 22.8) (33). Metronidazole and silversulfadiazine are the preferred antimicrobials to control anaer­obic infections in tumors. They will usually control superficialinfections within 5-7 days. If the infection is deep into thetumor, or invades surrounding tissues, add systemic metron­idazole 250-500 mg p.o. or i.v. q8h until the infection clears.Caution patients not to drink alcohol while receiving metron­idazole. If there is obvious candidal growth or a lot of crusting,mix a topical antifungal, for example, ketoconazole, with thetopical antibiotic or alternate them.

Control Bleeding

Bleeding is a common problem in malignant wounds. AstumOrS outgrow their blood supply, their surfaces becomefriable, coagulation is frequently impaired, and they becomepredisposed to oozing from microvascular fragmentation orfrank bleeding if a small or large blood vessel is involved.

Dressings may adhere to the 'wound and tear the surfacewhen the dressing is removed. For this reason, saline wet-to­dry gauze dressings are contraindicated in the management ofmalignant wounds. If dressings adhere to the wound surface,moisten them with normal saline or water to reduce adherenceand facilitate removal. Remove each dressing slowly, startingfrom the edges. If you can anticipate that there will be pain,or if there is any pain during the removal process, beforecontinuing start on preemptive anaesthesia/analgesia until thepatient is comfortable (discussed later in this chapter).

When wound surfaces are particularly friable, apply aninert, nonstick, nonabsorbent synthetic polymer mesh, forexample, Mepitel, as the first dressing layer. This does not

250 Section I: Symptoms and Syndromes • Part D: Skin

need to be removed, and other dressings can be changedroutinely with much less risk of tissue disruption and bleeding.

If oozing is significant, duririg each dressing change apply5-10 mL of low-dose topical thromboplastin as a sprayacross the wound surface to stimulate coagulation (the 100or 1,000 units per mL solution is as effective as higher­concentration solutions, and is less expensive). A 0.5-1 % silvernitrate solution may be equally effective. Antifibrinolytics, suchas topical aminocaproic acid, are occasionally used, althoughtheir role is not clear because fibrinolysis is not a majormechanism in wound bleeding.

Alginate dressings are hemostatic and can be left in placeas the primary dressing layer for several days. They turnto jelly on absorbing fluids from the wound and are easilywashed off, even in the shower, with minimal trauma to thewound surface. Hemostatic surgical sponges may be equallyeffective.

A short c.ourse of high dose per fraction palliative radiationtherapy (typically 250-800 cGy/fraction/day) will sclerosemost vessels and stop bleeding from a malignant wound injust a few days (42).

For frank bleeding, try silver nitrate sticks, electrocautery,andlor apply gentle pressure for 10-15 minutes. Intervenrionalradiology may be able to stop bleeding from a larger bloodvessel by sclerosing it.

In all situations where bleeding is a significant risk, discussthe situation with the patient, family, and caregivers anddecide on how and in what setting everyone will cope witha major catastrophic bleed. If bleeding occurs uncontrollably,dark towels lessen the sight of blood and reduce anxiety ofthe family, caregiver, and staff. If the patient is aware anddistressed by the protracted bleeding, sedation with a rapid­acting benzodiazepine (e.g., midazolam or lorazepam) may bewarranted.

Dress the Wound and Surrounding Tissues

Follow the same dressing principles outlined in the precedingtext for pressure ulcers. Layer the dressings in a manner similarto the approach used for a stage III or N pressure ulcers.

1. Keep the malignant wound continuously moist. Do notlet a necrotic wound surface dry out. It will be muchmore susceptible to cracking, bleeding, and infectionwith anaerobes and candida.

2. Control exudate in a manner similar to pressure ulcers.When there are copious exudates (e.g., malignant fistulaefrom the GI tract), stomal appliances or suction devicessuch as VAC therapy may be needed to cope with thevolume (see http://www.kcil.com/35.asp).

3.. Keep surrounding skin dry in a manner similar topressure ulcers.

4. Eliminate dead space by filling it with nonadherentdressing materials.

5. Consider caregiver time, skill and burden. Care for amalignant wound with copious exudate or bleeding canbe burdensome and psychologically difficult, particularlywhen the wound is in the head and neck area. Healthcare professionals (Heps) and family .caregivers willneed a lot of skill building and support to ensure thatthey adhere to the plan of care effectively.

6. Monitor dressings applied near the anus. They tend tomove and bunch up under the tremendous friction andshearing forces in the sacral area.

7. Dress in layers. Use the same layered technique as foradvanced pressure ulcers. Hydrogels and alginates areideal for friable malignant wounds as they liquefy asthey absorb fluids, and can be washed off easily, even inthe shower. Alginates are also hemostatic and conformeasily to the many crevices and contours of a malignant

wound. Other nonstick dressing, for example, Telfa,will protect and minimize the trauma to a dry malignantwound when the dressing is changed. Ensure that theouter layer is fashioned to optimize t~e aesthetics for thepatient and the family.

ASSOCIATED ISSUES

Odor

Odor emanating from wounds is caused by putrefying tissueandlor infection. When the odor is fruity and there is a greentinge on the wound surface, it is likely .emanating fro,?- .apseudomonas infection. When the odor IS fouVputnd, It IS

caused by an anaerobic infection in necrotic tissue.Foul odor can be very distressing to the patient, family,

and caregivers. It can lead to embarrassment, depression, andsocial isolation (43).

Odor management includes the following:

1. Debride putrefying tissues. Cleanse the wound carefullyto -remove any purulent exudate and then debride asmuch of the necrotic tissue as possible. Treat odorousdressings as biologically contaminated waste. Place themin a plastic puncture-resistant bag and close it securely.Double bag the waste and place in a tightly sealed trashcontainer for pickup and disposal.

2. Control infection. If "healing" is not the goal of woundcare, cytotoxic cleansers can be used to kill bacteria.Iodine will help keep the wound clean, although somepatients find it irritating and painful. For pseudomonas,0.0025% acetic acid may help inhibit the organism'sgrowth in addition to a topicalandlor systemic antibiotic(Table 22.8).If there is superficial anaerobic infection, topical treat­ment with metronidazole or silver sulfadiazine may besufficient. If there is a deeper tissue infection, add sys­temic metronidazole 250-500 mg p.o.li.v. q8h until theinfection resolves.

3. Modify the environment. There are multiple environ­mental changes that will help patients and families copewith foul odors, including the following:a. Ventilate adequately. Open windows to a1l9w fresh

air into the environment. Run a fan on a low speed sothat it circulates air around the room without chillingthe patient .

b. Absorb odors. Place inexpensive kitty liter or acti­vated charcoal in a flat container with a large surfacearea under the patient's bed. As long as the air in theroom is circulating freely, odors will diminish rapidly.Alternately, burn a flame, for example, a candle, tocombust the chemicals causing the odor.For particularly odorous wounds, place an occlusivedressing that contains charcoal or a disposable diaperover the wound to contain the odor.

c. Alternate odors. Introduce an alternate odor that istolerable to the patient and family, for example,aromatherapy, coffee, v·anilla, or vin.egar. Avoidcommercial fragrances and perfumes as many arenot tolerated by patients with advanced cancer.

Pain

Pressure ulcers and malignant wounds are often painful unlessthe patient is paraplegic or has an altered sensorium (44-47).The pain can be constant with or without breakthroughpain, or acute. Constant pain can be the result of a local

Chapter 22: Management of Pressure Ulcers and Fungating Wounds 251.

: tissue reaction, underlying cancer, infection, the products ofinflammation or increased pressure at a bony prominence.Intermittent acute pain occurs with specific procedures, forexample, debridement. Cyclic acute pain occurs with recurringdressing changes (48-50).

To appropriately treat wound-related pain, it is importantto know if the pain is nociceptive in origin, that is, the result ofnormal nociception and nerve function, neuropathic in origin,that is, the result of abnormal nerve function, or mixed.

Pain management follows standard pain managementprinciples:

1. Treat the underlying cause. Where possible treat thecancer, control infections, heal the wound, and/or movethe pe,tienr to a pressure-reducing or relieving surface.

2. For constant pain. Provide oral analgesics around theclock. If pain is nociceptive in origin, particularly if it isassociated with in£I.ammation, it will likely respond toa nonsteroidal anti-inflammatory drug (NSAID) and/oran opioid analgesic dosed once every half-life. If thepain is neuropathic in origin, a tricyclic analgesicor an anticonvulsant may be needed as an effectivecoanalgesic.For breakthrough pain, provide 10% of the total 24­hour oral dose of opioid every 1 hour as needed.Early evidence suggests that topical opioids mixed into ahydrogel, for example, morphine 0.1-0.5%, and placedagainst the wound surface in the primary dressing layermay reduce constant wound pain (51,52).Please note that if "healing" is the goal of woundcare, NSAIDs may interfere with angiogenesis and delaywound healing (53).

3. For both intermittent and cyclic acute pain. Providepreemptive anaesthesia and/or analgesia. Ensure thatthe pharmacokinetics of the medication closely followthe temporal profile of the pain.

During debridement, acute intermittent pain will likely lastonly as long as the procedure. If there is an es'char to debride,score it, then apply EMLA (eutectic mixture of long-actinganaesthetics) "like icing on a cake" 30-60 minutes before theprocedure, and cover it with an occlusive film. If there is sloughand debris to be removed, apply a 2--4% lidocaine solution tothe open wound. If there is likely to be pain at the peripheryof the wound, inject s.c. lidocaine (± epinephrine to minimizebleeding) into the surrounding tissues and leave it for 5-10minutes before commencing debridement.

Similarly, during dressing changes, acute cyclic pain willlikely last only as long as the procedure (54,55). As the edgesof the dressing are being slowly removed, moisten the woundand the dressing with a 2--4 % solution of lidocaine. Allowenough time for the patient to be comfortable.

Careful selection of dressings to minimize tissue adherence,for example, hydrogels, alginates, and nonstick dressings,will minimize pain during dressing changes. If pain persists,consider reducing the frequency of dressing changes.

H local anaesthesia is insufficient, try a very short actingopioid, for example, systemic fentanyl or inhaled nitrousoxide (56).

SUMMARYChronic wounds are relatively common in patients with ad­vanced cancer. After doing a comprehensive, whole personassessment, consider what the goals of care and treatment planfor the wound wiH be in light of the context of the patient'sunderlying cancer (and other comorbidities). Always use ther­apies that aim to reduce the risk of developing pressure ulcers.Once a pressure ulcer develops, if the goal is to heal it, follow

the conventional wound healing strategies outlined in the text.If the goal is to stabilize, but not heal either a pressure ulcer or·a malignant wound, the management will depend on whetherthe wound is dry or wet. Leave dry, noninfected wounds alone.For wet wounds, use relatively conservative wound cleansing,debridement, and dressing strategies to control infection andodor and minimize bleeding and pain.

Patients living with chronic wounds are inevitably"wounded" far beyond their physical wound. They live fromday to day knowing that someone will be putting herlhis handsinto their body for daily dressing changes. Exudates, bleed­ing, and odors are embarrassing and distressing. Emotionsfrequently run high. Anxiety and depression are common, par­ticularly in the face of multiple unexpected losses. Changesin intimacy, relationships, and finances can be dramatic andeven lead to social isolation. Questions of meaning, value, pur­pose in life, "why me," and so on, all surface. To successfullymanage these patients, interdisciplinary care must focus on thewhole "wounded" person, not just the "hole."

All URLs were last accessed February 19, 2006

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