Advanced-stage pressure injuries, or pressure ulcers, are a difficult and increasingly common problem whose challenges persist long after the completion of surgery. Meticulous postoperative care and timely management of complications are critical to a successful outcome.
During the Symposium on Advanced Wound Care (SAWC) 2020 virtual meeting, John C. Lantis II, MD, the vice chairman and a professor of surgery at Mount Sinai West and St. Luke’s Hospitals/Icahn School of Medicine, in New York City, discussed risk factors associated with recurrence after surgery and presented several nonsurgical options for managing pressure injuries.
As Dr. Lantis explained, the standard nonsurgical treatment for a clean, full-thickness pressure ulcer is wound cleansing followed by topical dressing, pressure redistribution, elimination of drainage, and supportive care. With this approach, six-month healing rates are 40% to 45% for stage III ulcers and 31% to 34% for stage IV ulcers (J Am Geriatr Soc 2004;52[3]:359-367).
For patients who undergo flap reconstruction surgery, however, a large retrospective study showed a complication rate of 58.7% (Plast Reconstr Surg Glob Open 2017;5[1]:e1187).
“In patients with low body mass index, ischial pressure ulcers, diabetes and active smoking habits, surgical interventions may have more limited success,” said Dr. Lantis, who noted various perioperative protocols. “It’s important to maximize nutrition, control blood pressure, and utilize off-loading techniques.
“For ischial tuberosity pressure injuries, patients should wait at least six weeks before sittings and start with just 10 minutes of sitting at a time,” he added.
According to Dr. Lantis, recurrence and nonoperative management of pressure injuries are often identical, and patients who recur after flap reconstruction surgery rarely return to the OR. Dr. Lantis summarized the evidence for several nonsurgical treatment approaches:
Debridement: A retrospective chart review of sacrum, sacrococcyx, coccyx, ischium and trochanter region pressure injuries showed that bedside surgical debridement using a sharp excisional technique was performed on 190 of 319 (59.5%) of wounds (Wounds 2017;29[7]:215-221). Of those 190 wound sites, 138 (73%) had a reduction in square surface area, and there were a total of 43 (23%) wounds that had a square surface area of 0 (reepithelialized), which has a healing rate of 23%.
Negative pressure wound therapy:
Overall, there is low-quality and inconclusive evidence regarding the clinical effectiveness of negative pressure wound therapy as a treatment for pressure ulcers, who cautioned against routinely offering this treatment unless it is necessary to reduce the number of dressing changes (e.g., in a wound with a large amount of exudate).
Cellular and tissue-based therapy:
Results of a small randomized study suggest that weekly treatment of chronic pressure ulcers with small intestinal submucosa wound matrix increases the incidence of 90% reduction in wound size versus standard of care alone (J Tissue Viability 2019;28[1)]21-26).
Transdermal topical oxygen: A single-blind, multicenter, randomized controlled trial found greater wound healing in the experimental group after 12 days of wound oxygen therapy, which suggests this approach may promote wound healing in patients with pressure ulcers (Iran Red Crescent Med J 2015;17[11]:e20211).
Stem cell therapy: Preliminary data indicate that cell therapy using autologous bone marrow mononuclear cells could be a treatment option for stage IV pressure ulcers in patients with spinal cord injury and could help avoid major surgical intervention (J Spinal Cord Med 2011;34[3]:301-307). In 19 patients (86.36%), the pressure ulcers treated with this approach had fully healed after a mean time of 21 days.
Anabolic steroids: A trial ended early after interim results demonstrated an unlikely benefit from treatment with oxandrolone (Cochrane Database Syst Rev 2017;6[6]:CD011375). There is no high-quality evidence to support the use of anabolic steroids in treating pressure ulcers.
Based on a review of the literature, postsurgical dehiscence can be well managed with ongoing sharp debridement, and topical oxygen therapy may help facilitate these closures,” Dr. Lantis concluded.
Dr. Lantis has been a consultant to, or a principal investigator for, 3M, Coloplast, Integra, Kerecis, MediWound, Pluristem, Smith & Nephew and TissueTech.
This article is from the December 2020 print issue.