Treatment of bedsores

Treatment of decubitus should be aimed at restoring skin in the area of decubitus. Depending on the stage of the process, this can be achieved by conservative measures (cleaning the wound, stimulating the formation of granulations, protecting them from drying and secondary infection) or surgically (surgical removal of necrosis and plastic closure of the soft tissue defect). Regardless of the method of treatment, a properly organized care is of great importance: frequent changes in the patient's position, use of anti-bedsore mattresses or beds, prevention of traumatization of the granular tissue of the decubitus wounds, adequate nutrition with sufficient protein and vitamins.

When choosing a treatment strategy, one should clearly formulate the goal and the tasks to be accomplished. At the stage of the primary reaction, the purpose is to protect the skin; at the stage of necrosis - a reduction in the duration of this stage by removing necrotic tissues that support the inflammatory process and intoxication; at the stage of formation of granulations - the creation of conditions that promote the faster development of granulation tissue; at the stage of epithelization - acceleration of differentiation of young connective tissue and production of epithelial tissue.

Most pressure ulcers are infected, but the routine use of antibiotics is not recommended. Indications for the appointment of antibiotic therapy are bedsores of any stage, accompanied by a syndrome of systemic inflammatory reaction and development of purulent-septic complications. Given the polymicrobial nature of the infection caused by aerobic-anaerobic associations, empirically prescribed preparations of a wide spectrum of action. Protected beta-lactam antibiotics [amoxicillin + clavulanic acid (augmentin), ticarcillin + clavulanic acid, cefoperazone + sulbactam (sulperazone)], fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin) or cephalosporins of III-IV generation in combination with clindamycin or metronidazole, carbapenems [imipenem + cilastatin (thienam), meropenem] and other regimens. After receiving the sensitivity data, the microflora is switched to the directed antibacterial therapy. Such practice in most cases of complex treatment allows to cure local and general inflammatory phenomena, demarcate necrotic tissues or prevent their development. The use of antibacterial drugs without taking into account the sensitivity of microflora does not reduce the number of complications, but only leads to a change in the composition of microorganisms, the selection of strains resistant to antibiotics.

Local treatment of decubitus is a rather complex problem, as it is not always possible to completely exclude the causes leading to their development; In addition, patients with bedsores are often weakened by a prolonged severe illness accompanied by anemia and malnutrition. All phases of the wound process in the presence of decubitus are sharply stretched in time and can be many months and even years. Local changes are heterogeneous, often simultaneously observe the sites of both necrotic and granulation tissue.

The result of treatment largely depends on adequate local effects, which is one of the most important components of complex therapy for patients with bedsores. Treatment of pressure sores currently uses the entire arsenal of dressings, which are used, in accordance with the indications for the use of a dressing, taking into account the stage and features of the course of the wound process.

In combination with anti-bedsore measures and local therapy, physiotherapy, general restorative therapy, full enteral and parenteral nutrition are widely used.

Bedsores III-IV degrees are characterized by the development of necrotic skin lesions to the full depth with involvement of the subcutaneous fatty tissue, fasciae, muscles in the destructive process, and in more severe cases and bones. Spontaneous cleansing of decubitus from necrosis occurs for a long time; Passive management of a purulent wound is fraught with the development of various complications, the progression of purulent-necrotic changes, the development of sepsis, which becomes one of the main causes of death of patients. In this regard, patients with similar bedsores treatment should begin with a full surgical treatment of a purulent focus with the excision of all non-viable tissues, a wide dissection and drainage of pockets and purulent feces.

The surgical treatment of decubitus is determined by the stage and size of decubitus, the presence of purulent-septic complications. In the case of development of pressure ulcers by the type of moist progressive necrosis, surgical treatment is performed on urgent indications, which allows to prevent the spread of putrefactive destruction to surrounding tissues, to reduce the level of intoxication and to achieve faster delimitation of necrosis. In other cases, necrectomy should be preceded by anti-inflammatory therapy (antibacterial and topical therapy, physiotherapy), which allows demarcation of the necrosis zone and to stop inflammation in surrounding tissues. Otherwise, the wrong surgical procedure can only increase the area of the ulcer and provoke the progression of necrosis.

When performing necrectomy, it is most difficult to determine the viability of tissues. The main task of surgical treatment is surgical removal of obviously devitalized tissues to the zone of bleeding sites appearance. Widespread excision of pressure sores within visually unchanged, but already exposed tissues, often becomes an error and is not always advisable, as it often leads to the formation of an extensive zone of secondary necrosis.

Further treatment aimed at purging the decubitus ulcer from purulent exudate and necrosis residues, absorbing the detachable and retaining a moist environment in the wound, is associated with adequate local therapy. In the formation of secondary necrosis, repeated surgical procedures are performed until the decubitus ulcer is completely cleared from the necrotic tissues. Treatment of decubitus in phase I wound process is the use of various methods of additional wound treatment (ultrasonic cavitation, laser ablation of necrosis, the use of a pulsating jet of antiseptics and vacuum aspiration).

In patients with lower paraplegia and occlusive lesions of the arteries of the lower extremities, in some cases it is necessary to decide the question of amputation or exarticulation of the limb. Multiple extensive bedsores of the lower extremity, which are not resistant to conservative treatment for a long time and are accompanied by persistent intoxication, serve as an indication for limb amputation at the level of the shin or thigh, depending on the prevalence of purulent-necrotic changes and the zone is guaranteed for good blood flow. When the above changes are combined with the decubital ulcer of the large trochanteric region complicated by purulent coke and osteomyelitis of the femoral head, the extremity is exarticulated in the hip joint. In the presence of pressure sores in the region of sciatic tubercles, perineum and sacrum, it is advisable to use musculoskeletal flaps of the scapular limb for the plastic of the above defects.

Spontaneous closure of pressure ulcers occurs for a long time, it is associated with the development of various life-threatening complications of the patient and is possible only in a small part of the patients. In most cases, self-healing of the decubital ulcer is impossible or difficult, since there are reasons that lead to ulceration, or the size of decubitus is too great.

The conducted randomized clinical studies did not reveal any significant differences in the time of healing of decubitus defects with the use of surgical treatment of the purulent necrotic focus and skin-plastic interventions in comparison with conservative methods of treatment. Meanwhile, the analysis of these studies shows not so much the inefficiency of these methods, but rather the insufficient evidence of their effectiveness.

The surgical method in some cases remains the most radical, and sometimes the only possible treatment for decubitus. In our country, up to the present time, surgical treatment of decubitus is purposefully performed only in single surgical units, whereas in most developed countries there are centers for plastic surgery for decubitus ulcers. In the US for the treatment of decubitus in spinal patients, annually from 2 to 5 billion dollars. It is noteworthy that the direct costs associated with surgical intervention are only 2% of the cost of the entire treatment, while a significant part of the funds is spent on conservative measures and rehabilitation of patients.

Most leading surgeons, professionally performing bedsore treatment, are convinced that at the present stage of medicine surgical orientation with the use of plastic methods of wound closure should become a priority in treatment. Such a tactic allows to significantly reduce the frequency of complications and relapses of pressure ulcers, reduce the level of mortality and the terms of rehabilitation of patients, improve the quality of life and reduce the cost of treatment. Preceding this should be adequate preparation of the patient and a wound to plastic interference. The successful outcome of the treatment of decubital ulcers is closely related to the integrated approach to treatment. It is necessary to completely exclude pressure on the area of decubitus, to purposefully carry out other anti-bedsore measures and quality care. The patient should receive adequate nutrition. It is necessary to eliminate anemia and hypoproteinemia, sanitize other foci of infection.

Skin plasty, like the treatment of decubitus, should be used when there are no general and local contraindications to surgery and faster healing of the wound defect and a smaller number of complications is predicted compared with spontaneous wound healing.

Indications for skin-plastic interventions

• the extensive size of decubitus ulcers, which do not allow expecting its spontaneous healing;
• absence of positive dynamics (reduction in size by 30%) in the healing of decubitus ulcers with adequate conservative therapy for 6 months or more;
• the need for urgent surgical interventions requiring the rehabilitation of foci of infection (orthopedic surgery, heart and vascular intervention);
• need to fill the skin defect with vascularized tissues to prevent the development of relapse of decubitus (applicable for spinal and other inactive and immobilized patients).

Skin and plastic interventions are possible if the following conditions are met:

• stable general condition of the patient;
• stable transition of the wound process to phase II;
• the ability to close a pressure ulcer without excessive tension of the tissues;
• the possibility of adequate post-operative treatment and care for the patient.

Contraindications to cutaneous plastics are closely related to the peculiarities of the local wound process, the general condition of the patient, unpreparedness of the staff for such interventions:

• decubitus ulcer, located in phase I wound process;
• lack of a sufficient amount of plastic material, which makes it possible to close the pressure sore defect without hindrance;
• the presence of diseases and conditions with a predicted life expectancy of less than 1 year (cancer, severe strokes);
• unstable mental state of the patient, accompanied by periods of excitation, inadequate behavior, frequent convulsive attacks, the state of soporus and coma;
• rapid progression of the underlying disease (multiple sclerosis, repeated strokes), decompensation of concomitant diseases (severe circulatory insufficiency, respiratory failure);
• occlusive diseases of vessels of the lower extremities (with localization of pressure ulcers below the waist);
• absence of skills and special training of surgeons for carrying out the required skin-plastic interventions.

PM Linder in 1990 formulated the basic surgical treatment of decubitus:

• absence of signs of infection and inflammation in the area of decubitus and surrounding tissues;
• during the surgical intervention the patient is laid in such a way that when the wound is sutured, the greatest tension of the tissues is ensured;
• all infected, contaminated and scar tissue in the area of the pressure sore should be removed;
• In the case of osteomyelitis or the need to reduce the underlying bone protrusions, osteotomy is performed;
• line cutaneous incision or formation of a seam should not pass over the bone protrusion;
• formed after excision of pressure ulcer, the defect is filled with a well-vascularized tissue;
• to eliminate dead space and prevent the formation of seroma, the wound is drained by a closed vacuum system;
• After the operation, the patient is placed in a position that excludes pressure on the wound area;
• After the operation, the patient is prescribed directed antibacterial therapy.

To eliminate decubital ulcers, it is possible to use various methods of surgical treatment. Arsenal of plastic interventions is currently quite wide and varied and allows stable patients to close bedsores of almost any size and location. Types of skin-plastic interventions in bedsores:

• autodermoplasty;
• plastic by local tissues with the use of: - simple bias and sewing of tissues;
• dosed tissue stretching;
• VY plastics by shearing skin-muscle grafts;
• combined methods of skin plasty;
• free transplantation of tissue complexes on microvascular anastomoses. Such interventions as isolated autodermoplasty, now
• time have only a historical interest. In a number of cases, it is advisable to use it to temporarily close the pressure sore defect as a preparation stage for the patient. Plasticity split skin flap is also possible when closing large surface defects that do not carry a supporting function and are not subjected to a constant load (chest, scalp, shin). The use of autodermoplasty in other situations is unjustified, since it leads to the formation of an unstable scar and relapse of decubitus.

Plastic surgery by local tissues through excision of pressure ulcers and simple suturing of a wound defect is possible with small bedsores without osteomyelitis of the underlying bone and, if possible, closure of the wound with sutures without tension. With a high risk of recurrence, decubitus plastic by simple flipping of the flaps and sewing of tissues is useless to use.

In case of excessive stretching of tissues, the method of dosed tissue stretching is used. For this, after excision, pressure sores produce a wide mobilization of skin-fat or skin-fascial flaps, the wound is drained, frequent stitches are applied to it, they are tightened with safe tension and tied to a "bow". The remaining diastasis of the wound is subsequently eliminated by systematic daily (or less frequently) traction of the flaps with the help of ligatures. Upon reaching the contact of the flaps, the threads are finally knotted and cut.

The presence of extensive and recurrent decubitus ulcers and a lack of local plastic material make it widely used the method of tissue balloon expansion. The tissues are expanded both in the immediate vicinity of the wound defect, and in some distance from it. To do this, through a section of the fascia or muscle, insert a silicone expander balloon, which is filled slowly, for 6-8 weeks, with a sterile saline solution. After reaching the necessary dilatation of the tissues, the expander is removed, a flap is formed and moved to the pressure sore defect.

In most cases of decubitus ulcers, preference is given to the use of skin-fascial or musculocutaneous flaps located in the immediate vicinity of the defect or away from it. The advantage of such flaps is that with their help they replace a previously ischemic area with well-supplied blood-supply tissues. The displaced musculocutaneous flap serves as a soft lining in a site subject to constant pressure. It participates in the uniform distribution of pressure, depreciation and avoids the recurrence of bedsores.

Currently, transplantation of tissue complexes on microvascular anastomoses in the treatment of decubitus is less common than with local dermal plasty. This is due to the technical difficulties of the intervention, which requires special surgical preparation and equipment, frequent postoperative complications. In addition, local plastic resources are in most cases sufficient to adequately fill decubitus defects, and interventions are technically simpler, less complications, and easier to tolerate by patients.

Skin and plastic interventions for pressure ulcers have their own characteristics. Stop bleeding even from the smallest vessels in patients with paraplegia is a significant difficulty due to the inability of the vessels to vasoconstriction, and therefore the wound must be drained longly with one or more catheters followed by vacuum aspiration. In the case of osteomyelitis, the underlying bone is removed from the bone within the bleeding bone tissue. In spinal patients, even in the absence of osteomyelitis for the prevention of recurrences of decubital ulcers, it is necessary to perform a resection of the bony projections (sciatic tubercle, large spit). When adapting skin flaps to the bottom, the edges of the wound and to each other, you should use resorbable threads on the atraumatic needle. All residual cavities should be eliminated by layer-by-layer closure of the tissues in several floors.

Treatment of pressure ulcers in the sacral region

Pressure ulcers of the sacrum usually have large sizes with overhanging skin edges. Directly under the skin are the sacrum and coccyx. Vascularization of this area is good, it is carried out from the system of the upper and lower gluteal arteries, which give multiple anastomoses. Intervention begins with complete excision of pressure sores and surrounding scar tissue. If necessary, remove the protruding parts of the sacrum and coccyx.

With the plastic of small and medium sacral decubitus, the rotary gluteal dermal-fascial flap has proved to be well established. The flap is cut in the lower part of the gluteal region. The cut of the skin is carried out from the lower-side edge of the pressure sore defect strictly downwards, parallel to the mezhyagodic fold, then the cut line is rotated at an angle of 70-80 ° and leads to the external surface of the buttock. The size of the flap to be formed must somewhat exceed the size of the decubitus. The flap is cut out together with the gluteal fascia, rotated on the area of the pressure sore defect, hemmed to the bottom and edges of the wound. The donor defect is closed by moving and suturing skin-fat flaps of type VY plastic.

Plastic surgery with an isopharyngeal upper musculoskeletal flap of C. Dumurgier (1990) is mainly used to close the pressure ulcers of medium size. For this, a skin flap of the necessary shape and size is cut out above the large spit. Without breaking the connection with the large gluteus muscle, cut off the latter from a large spit. The cutaneous muscle flap is mobilized and, through the subcutaneous tunnel, is led to the pressure sore defect, where it is fixed with sutures.

For the plasty of large decubitus ulcers, usually two skin-fascial or musculocutaneous flaps are used. Flaps are formed from the lower or upper parts of the gluteal region or use one upper and one lower gluteal flap. When plastic Zoltan (1984), cut out the two upper cutaneous muscle flaps. Cutaneous incisions lead from the upper side of the decubitus to the posterior upper tip of the ilium, then they are rounded and carried down to the level of the conditional line passing through the lower edge of the pressure sore defect. The flaps formed include large gluteus muscles, which cut off from surrounding tissues, without disturbing their connection with the skin flap. Formed flaps rotate on the area of pressure ulcer, without tension, fix the seams to the bottom, the edges of the wound defect and to each other. Donor wounds are closed by moving tissues and suturing them as VY plastics.

Wide spread for the plasty of large bedsores got an islet sliding muscular-muscular VY flap according to Heywood and Quabbu (1989). On the edges of the excised sore, two large triangular flaps are formed in the form of the letter V, with the point of the arrow pointed toward the large spit, and the base towards the bedsore. The incisions continue deeper with the dissection of the gluteus fascia. The large gluteus muscle is mobilized, cutting it from the sacrum, and with insufficient mobility - from the large trochanter and the ilium. Blood supply to skin flaps is good, carried out through a variety of perforating gluteal arteries. After the appearance of sufficient mobility, the flaps are displaced medially in a direction to each other and, without tension, are laminated together layer by layer. The lateral areas of the donor wound are closed in such a way that the seam line takes the Y-shape.

Treatment of pressure sores for the large trochanter area

Bedsores of the large trochanteric region are usually accompanied by the development of a small skin defect and extensive damage to the underlying tissues. The bottom of the decubitus ulcer is the large spit. Excision of the decubital ulcer is performed extensively, together with the scars and bursa of the large trochanter. Perform a resection of a large trochanter. For the plasticity of the defect formed, the skin-muscle flap of tenzor fasciae latae no F. Nahai (1978) is most often used. The flap has a good axial blood supply from the branches of the lateral envelope of the artery of the thigh. The length of the flap can be 30 cm or more. In the distal part the flap is dermal-fascial, in the proximal part - skin-muscular. After rotation of the flap 90 °, the musculocutaneous part of the flap lies on the area of the resected large trochanter. The distal dermal-fascial part of the flap without special strain fills the remaining part of the decubitus defect. In the presence of large subcutaneous pockets, de-epithelialization of the distal part of the flap is carried out, which is invaginated into the pocket area and sealed, thereby eliminating the residual cavity. Donor wound is easily closed by the displacement of additional mobilized skin flaps and the application of vertical U-shaped seams.

With VY plastic according to Paletta (1989), a large triangular flap with a wide base that extends beyond the margins of the pressure sore defect is distal to the pressure ulcer. The wide fascia of the femur is dissected, the flap is displaced proximally and completely covered by the wound defect. The donor wound is closed with local tissues with the formation of a Y-shaped seam.

Other types of plastics with the use of osteoporotic musculocutaneous flaps cut from rectus femoris, and so on, vastus lateralis, are used much less frequently.

Treatment of decubitus bedsores

With bedsores in the area of the ischiatic tubercles, the skin defect usually has small dimensions, but underneath it there are extensive cavities of the bursa. Osteomyelitis of the buttock of the ischium is often noted. In surgical treatment, additional difficulties arise in connection with the proximity of the vessels and nerves, as well as the rectum, urethra and cavernous bodies of the penis. Total removal of the ischial tuber is fraught with pressure ulcers and perineal diverticula, urethral strictures, rapid development of a similar decubitus in the region of the ischiatic hillock on the opposite side, and therefore it is more advisable to perform only a partial resection of the bony projections.

For the plasty of decubitus ulcers of the sciatic region, the most widely used rotatable lower ligament musculoskeletal flap is Minami (1977). The flap is abundantly blood flowing with branches of the lower gluteal artery. It is cut in the lower part of the gluteal region, the muscle is cut off from the femur. The flap is rotated on the area of decubitus ulcers and fixed with sutures. Donor wound is closed after additional mobilization of tissues.

For the plasticization of sciatic ulcerative ulcers, you can also use the rotated gluteal femoral musculocutaneous flap according to Hurwitz (1981), the shifting musculocutaneous VY flaps of the biceps femoris according to Tobin (1981).

With the development of extensive decubitus ulcers of the sciatic cusp in combination with ulcers of the perineum, an islet musculocutaneous flap on gracilis proved to be well established. The flap is fed by the branches of the inner envelope of the thigh of the artery. A skin flap of the necessary shape and size is formed on the posteromedial surface of the middle third of the thigh. The tender muscle is cut off in the distal part. The islet musculocutaneous flap is rotated 180 ° and through the subcutaneous tunnel leads to the area of the pressure sore defect, where it is fixed with sutures.

Treatment of decubitus decubitus

The most frequent localization of decubitus ulcers is the posterior part of the calcaneal region. Skin defects are usually small. The incidence of osteomyelitis in the calcaneus is about 10%. Treatment of bedsores of this localization is a significant problem due to the lack of a sufficient amount of local plastic material and the frequent development of decubitus against the background of occlusive diseases of the vessels of the lower extremities. The ulcer is excised within the bleeding tissues. In the case of osteomyelitis, resection of the heel of the calcaneus is performed. For small ulcers, plastic is used with sliding skin-fascial VY flaps according to Dieffenbach. Proximal and distal to pressure ulcers form two flaps of triangular shape with a base in the defect area. They are mobilized from three sides, they are displaced aside ulcers until they come close to each other without tension of the tissues. The flaps are stitched together. The wound is closed in the form of a Y-shaped suture. The foot is fixed with a back gypsum longus in an equinus position. With medium-sized pressure ulcers, Italian skin plasty is used. The best results are given by the medial calf skin-fascial flap of the contralateral limb.

The need for skin plasty of bedsores of other localization is met much less often. The choice of the method of plastic closure of a defect can be very diverse and depends on the location and area of a chronic wound.

Postoperative treatment of pressure sores

In the postoperative period, it is necessary to exclude pressure on the area of the operating wound for 4-6 weeks. Drainages in the wound are left for at least 7 days. They are removed after reducing the discharge from the wound to 10-15 ml. Directed antibacterial therapy is canceled the next day after the removal of the drainage system. Sutures are removed for 10-14 days. With the development of suppuration in the area of several stitches, they are partially removed, economically diluting the edges of the wound with a daily sanation of the purulent focus and applying a dressing with ointment on a water-soluble basis or alginates. Antibacterial therapy is continued with massive suppuration of the wound or necrosis of the flap, accompanied by a systemic inflammatory reaction. With the development of marginal necrosis of the skin, its delimitation is achieved, for which bandages with solutions of antiseptics (iodopyron, povidone-iodine, dioxidine, lavasepit) are used. After demarcation of necrosis, it is excised. When the wound passes into stage II, bandages are used to treat wounds of this stage.