Definite management and closure of pressure related injuries

Jose A. Castro Garcia, MD, FACSPlastic and Reconstructive Surgery

Surgery DepartmentTTUHSC

Objectives

• Summarize preoperative criteria for final closure.• Explain approaches for closure according to location of the

lesion. • Review postoperative management.

• What caused it?• Why now?• Are there any reversable causes?• What is the patient’s overall clinical status?

Re-admission of patients with pressure ulcer

• After discharge from inpatient rehabilitation, patients with spinal cord injury, UTI is the most common reason for readmission, followed by pneumonia.

• Pressure ulcers are the most common complications overall.

• DVT and PE incidence is lowStillman MD, Barber J, Burns S, Williams S, Hoffman JM. Complications of Spinal Cord Injury Over the First Year After Discharge From Inpatient Rehabilitation. Arch Phys Med Rehabil. 2017 Sep;98(9):1800-1805. doi: 10.1016/j.apmr.2016.12.011. Epub 2017 Jan 20.

McKinley WO, Jackson AB, Cardenas DD, DeVivo MJ. Long-term medical complications after traumatic spinal cord injury: a regional model systems analysis. Arch Phys Med Rehabil. 1999 Nov;80(11):1402-10.

Pressure ulcer present on

admission or hospital acquired

Initial assessment and staging

Management of other medical issues

Non-Surgical

Discharge planningSocial Services

Case Management

- Diabetes, HTN, CAD- UTI- Pneumonia- Spasticity- Mood disorder- Drug, tobacco and alcohol use.- Malnutrition- Urine / stool diversion

- Wound care- Physical therapy- Occupational therapy- Specialty bed- Nutrition- Emotional / family

support

- Funding- LTAC / SNF- Hospice care- Home health

- CT / MRI- Initial debridement- Bone biopsy- Wound vac therapy

Final Closure

Goal of management of patients with pressure ulcer

1. Prevention of complications2. Preventing the existing wound from getting

larger3. Preventing sores in other locations4. Closure of the wound with tissue of adequate

thickness and minimal donor site morbidity

Tchanque-Fossuo, C; Kuzon, W. An Evidence-Based Approach to Pressure SoresPlastic and Reconstructive Surgery: February 2011 - Volume 127 - Issue 2 - p 932-939

Ideal preoperative criteria for closure• Albumin > 3.5 g/dL• HbA1C < 6.5• Prealbumin >20• Non-smoker• Hemoglobin > 10• Wound debrided and clean• Cardiology clearance if prior history of cardiopathy• Adequate antibiotic coverage for osteomyelitis if present with stable IV access• Urinary and stool diversion if needed• Adequate social support• Spasticity and contracture managed• Specialty bed• Postoperative placement arranged

Raetz JG, Wick KH Common Questions About Pressure Ulcers. . Am Fam Physician. 2015 Nov 15;92(10):888-94.Mervis T, Phillips J Pressure ulcers: Pathophysiology, epidemiology, risk factors, and presentation J Am Acad Dermatol. 2019 Oct;81(4):881-890 Epub 2019 Jan 18.

Bass MJ, Phillips LG. Pressure sores. Curr Probl Surg. 2007 Feb;44(2):101-43.

~50%

Closure of pressure wounds according to location

Guidelines for wound closure• Debride wound to healthy bleeding tissue.• Remove bursa (methylene blue).• Obtain deep tissue cultures, avoid swabs.• Use local tissue of adequate thickness.• Obliterate empty space• Drain liberally• Layered closure• Avoid pressure to flap