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Release Date: 03/16/2018 Expiration Date: 12/31/2018
Som Kohanzadeh, MD
CEO and President/Founder
SOM K Plastic Surgery
Director of Plastic Surgery
Director of the Center for Reconstruction and Wound Care
Sherman Oaks Hospital
Sherman Oaks, CA
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Male Speaker: I'm in the speaker’s bureau for innovation in MyMedics. As part of the objectives for our talk today, I'm going to go over some of the definitions of pressure ulcers, the pathophysiology, classification and then we’ll talk about some of the common treatments and then of course the use of amniotic membranes for treatment. The word decubitus in Latin comes from decumbere, which means to lie down. Pressure ulcer or decubitus ulcer is kind of an ambiguous term but the term pressure sore is one we prefer as a better description of the tissue loss as a result of pressure. Here we can see pressure sore, over bony prominences, therefore resulting in loss of tissue. How big of a problem is this? It's $3 to $7.5 billion of the US health system goes towards pressure sores, whether they're on the hips, on the sacrum, on the face, on the heels, on the malleolus, medial and lateral. Seventy eight thousand dollars per admission is added per patient. They're usually on the average of three months of treatment per pressure sore and a significant number of equipments that are required to help them heal during this process. The pathophysiology has three separate parts. It's based upon immobility and inactivity and sensory loss. These are the three keys and then of course pressure comes into play. In 1970 [indecipherable] [01:34], Fronek and Zweifach did pressure analysis with pressure mapping on a patient’s back side as well as laying both supine and prone. We can see some of the pressure points here. The thing that was important was they found the clinical pressure of significance is 32 millimeters of mercury because that’s the end capillary perfusion pressure. Any of the bony prominence is hard to see here but the centers of those circles are far beyond that, going all the way up to 60 millimeters of mercury. Those are not going to have any blood flow. What are the other factors that are important? Local ischemia, fibrosis, loss of autonomic controls for our paraplegic patients, edema, vessel disease, lowered mobility. Patients that are having difficulty walking and not ambulating as much anymore in their age, poor nutrition, infection and of course other wound healing problems that come into play. In the center, we have a pressure sore. Three factors leading to it are pressure, intrinsic factors and extrinsic factors that we talked about. Who has these kind of problems? The elderly patients that are less mobile, they have decreased nutrition, spinal cord injury patients obviously and then those that are immobilized for various reasons. Classification system, this is based upon the National Pressure Ulcer Advisory Panel from 1994. So, stage 1, 2, 3 and 4. One is skin intact with hyperemia, stage 2 has erosion into the dermis, 3, to muscle, and 4, down to bone. Going over them again, stage 1, we have some erythema centrally, stage 2, right down through the dermis to subcutaneous tissue, 3, down to muscle and then 4. But this is not really 4, right? This is actually an unstageable ulcer. For us to really know it's a 4, we have to debride it and get down to the bone underlying. What's the medical management? There are multiple aspects caring for these patients. The first part, nutrition, nursing, wound care, diversion of feces and urine to keep those areas clean and healthy, treatment of the spasms and then antibiotics if they have wound infections. Again, nutrition is key whether it be enteral or parenteral nutritional supplementation. Vitamins, vitamin A, especially if they're on steroids for whatever reason, vitamin C, zinc and then obviously other metabolic supplementation if needed. The key is that this is a multidisciplinary thing making sure that treatment is tailored per patient because each patient has different reasons for having the pressure sores. Team approach is key. We want to establish acute and chronic cares of treatment and then having ancillary services with wound care, nursing changes is also instrumental. Prevention, we want to make sure there's no moisture. We want to relieve pressure with Q2 hour turning protocols and low air loss mattresses and of course controlled spasticity because they increase those bony prominences and nutrition, nutrition, nutrition. What are the equipments that we have available? There's both static as well as dynamic equipment that’s supportive for pressure release, elbow pads, gel pads, heel cushions and then our low air loss mattress and fluid airbeds.
There we go. Okay. We have our fluid airbeds. This is one of the older machines made by KCI. We don’t really see this anymore. The majority look like this now. They're computerized air pads. They sense the weight distribution on the bed and then the air cells change accordingly. There are the static cushions. This is the standard cushion that’s used for wheelchairs. There are also similar ones for the beds. We have the more computerized air cells here. You can see multiple columns within the air pad. These are accustomed to each patient. They come in, they get fitted appropriately and then the wheelchair is made to prevent from bony erosions. Other things that are important are protection from infection. These patients are high risk for UTIs and pneumonias and then obviously osteomyelitis is a big problem. There's a 23% incidents in spinal cord injury patients, so we want to make sure to stay on top of this. Do the appropriate studies to rule them out and treat them accordingly. What else can we do? We want to make sure we debride the wounds if we need to, biopsies can be taken, which are the most effective way to diagnose these, and then treatment of the osteomyelitis is important as we said with biopsies, debridement and then appropriate antibiotic therapy. Other things with the wound debridements, we can use jet lavage and then getting good coverage for these patients. Some of the options are fasciocutaneous flaps. There are myocutaneous flaps as well where we can move around some muscle to bring good bulk for coverage. These are good for the stage 3 and 4 pressure ulcers. Obviously, we tailor the treatment for flaps per side whether it be sacrum, ischium or trochanteric wounds. The guidelines are simple. Make sure you remove any infected tissue and then bring in a good flap that can be moved again. In this typical patient who’s a paraplegic, he's got multiple wounds. We can then create the correct flaps and then advance the tissue as needed to get good coverage. Now, not all patients are good candidates for a flap. This is where our alternative therapies come in. Negative pressure is key and very hopeful and then obviously biologic and skin substitutes as well as topical agents. I think everybody is familiar with the wound VAC and other negative therapies. We can use them to really get the benefit we want. Now, with more and more biologics available, we’re able to target and treat these patients with alternative therapies and give them different options other than those large flap surgeries that most of them are not compliant with and often are not even candidates if their nutrition status is not up to par or they have other comorbidities. Why amniotic membranes? Human amniotic membrane has been used since 1910. So, over 100 years of data already exists. We know it's good because it's privileged tissue, so it actually decrease scar tissue formation. The other benefits are that they reduce inflammation, reduce scar tissue formation and then the key for at least the way when I think about them and use them is the growth factors that they have present within them. Similar to Dr. Pugash [phonetic] talk, I think we've already seen a couple of these slides but you can see there is a whole host of cytokines and chemokines available within the graft and these are part of the key to their efficacy. We can see in a dHACM, dehydrated human amniotic chorion membranes. Here's a graph demonstrating the difference between amnion alone, chorion alone and then their combination therapies and how they actually stimulate human dermofibroblasts growth. There's the angiogenic growth factors that I think particularly for these patients where flow is an issue, the angiogenesis is very important. The schematic shows a little bit of the effect when we put the tissue in there. It helps stimulate recruitment, proliferation and then ultimately angiogenesis into these patients that have difficult blood flow in issues with wound healing as a result of this.
The other things that’s helpful with the dHACM is the regulation of inflammation. A lot of these patients are stuck in a prolonged phase of nonhealing. They're stuck in this prolonged inflammatory phase right on that peak along the top. But actually doing an appropriate debridement, helping with the membrane can help jumpstart that wound again and get it back into the healing phase, why? Because of all the factors we already talked about, the chemokines, cytokines and then angiogenic growth factors. Similar to the picture Dr. Pugash had shown earlier, they actually have been proven to help stimulate stem cells to come embed into the graft. You place the graft where you need it and then stem cells from the host actually come and impregnate within the membrane itself and therefore stimulate wound healing. Cell analysis and patient examples. This is an 85-year-old male. He was admitted to the hospital with a bad pneumonia, was living at home before this, malnourished. He hasn’t eaten in a while but with these dirty infected wounds. The first step always is not different. We want to debride them first. He was in the operating room obviously. We debrided him all the way down to bone. You can see all three sites. Large wounds. He was malnourished as well so we made sure he got a peg. He got the appropriate therapy. We put him on antibiotics for a while, big large wounds, 9 by 7, 11 by 12, 10 by 8. We used our friendly VAC to help with these wounds and then started putting grafts on there. Like Dr. Pugash mentioned earlier, we have very large grafts that are amenable for this. They're various sizes, 7 by 7 is being one of the larger sizes. We used them on this patient and we were able to get in to start granulating in. We’re down on bone before and now we’re getting nice, healthy granular tissue. The wounds are decreasing in size. We were even able to get him to the point where we can a put a skin graft on and we got him to heal. Other things we can do on our other patients besides using the graft just to help stimulate wound closure, we can use it in combination with flaps. In this patient who had undermining of this wound, we took her to the operating room. She's 90 years old. We did bilateral myocutaneous flaps and then we put the membrane underneath to help stimulate the wound and give it increased angiogenesis for the closure and then we got her to close and stay closed. In summary, for treatment of all kinds of pressure ulcers whether they be sacral, trochanteric, ischial heals, preoperative evaluation is essential. What is the cause? Why is it happening? Treat the social aspects, make sure their systemic comorbidities have been dealt with, make sure they have adequate nutrition whether they need a feeding tube or alternatives that should be done first then wound control. Local wound care making sure they are in the appropriate antibiotics if they need them and then our variety of treatment methods whether it be autologous tissue with a flap or adjuvant therapies such as amniotic membrane in the wound VAC and then obviously postoperative care and rehabilitation. Of course, a multidisciplinary approach, making sure we have the therapist involved, primary care team infectious disease to make sure the patient has all the appropriate therapies that they need. Thank you.