When you apply pressure over an area of the body which is greater than the pressure within the blood vessels, the blood flow will diminish- this will reduce the oxygen supply and affect the metabolism and normal healing process which will ultimately result in breakdown of tissue and ulcer or wound formation. Such pressure ulcers commonly occur over the bony sites-(sacrum, shoulder blades, heel, back of head, ankles) in bedridden patients who are unable to move regularly to prevent sustained pressure over any particular area of the body. In these patients frequent change of position, maintaining hygiene, improving nutrition, using special mattress and beds to prevent sustained pressure over any specific site will help to prevent formation of pressure ulcer and also to heal them. However if a large non healing pressure ulcer should occur, you will need ‘external aid’ to heal them. The air fluidized bed is an excellent bed to prevent bedsores but is an expensive one. The lesser ones include the air mattress and others. Basically the idea is to avoid pressure at one spot of the body over more than an hour as this will start to reduce the blood flow and oxygenation which cannot be compensated by the body and will cause tissue breakdown and cellular death.
Wound infection is often a problem in bedsores as in pelvic sores like the sacral and ischial and trochanteric sores (buttock sores and around). This is because there is feces contamination and urine soiling of the wound and that causes wound infection. Meticulous hygiene and prevention of wound soiling with feces and urine will go a long way in helping to heal the wound. In some patients there may be no way except to do a colostomy (fecal diversion to the abdominal wall) which will prevent soiling of the wound. I once had a patient in whom we had to do both a fecal and urinary diversion as he had no control of both and the urine was constantly leaking into the wound through a urinary fistula. When wound infection is the problem, cultures will help to identify the culprit and appropriate antibiotics can be started. A variety of dressing materials are available depending on the status of the wound- e.g. for oozing wounds absorptive dressing should be used, for dry wound materials that keep the wound moist should be used.
Nutrition is an important feature for wound healing and in bedridden patients this is extremely important because these patients are not able to take care of themselves.
A lot of wounds will heal with these measures. The ones that don’t heal are the deeper ones like those where bone is exposed or those that are really big and wide or those that are badly infected or have a lot of dead tissue which needs to be surgically removed. These may need additional methods.
Vacuum assisted healing is a relatively new mode of treatment (though introduced in 1997 by Argenta) and is now being used more frequently. Incidentally in 1987 -88, I worked in Mahatma Gandhi memorial (MGM) hospital in Parel, Bombay, where I had a patient with multiple typhoid fistulas over the abdomen. He had been operated previously and with multiple intra abdominal adhesion the fistulas were difficult to be tackled surgically. While treating him as a registrar and faced with the task of changing his dressings multiple times a day, I realized that if we could apply some vacuum over his fistulas, we could prevent soiling of his skin. I then took a feeding tube applied it over the multiple fistula area (midline I recollect) and then applied a sticky steridrape over it, then a low power wall suction. It did work; I did not use any foam or gauze. As the discharge came from the fistula, it got sucked into the feeding tube and then into the wall suction unit. I kept a low pressure suction as i was worried of bleeding from the fistula. It kept both the surgeon, the patient and people around happy for two months as the patient expired after that. Dr Potnis my unit head was equally impressed. I had not taken any pictures at that time nor did I think this was of any significance (ignorance was bliss!!). Looking back if I had reported it at that time- it would probably have been the first case of a clinical VAC application and would have resulted in more interest and more researchers in this area at that time. It was only when I joined the dept of plastic surgery at LTMM College and hospital, under Dr Ravin L Thatte that I realized the importance of clinical documentation and reporting in journals and since then I have made it a point to report any important, new or unusual finding and have now more than thirty four papers published. Thanks to Dr Thatte my mentor!!!!
LTMMC Sion was a great place with Dr Thatte always stimulating us to think (without realizing we were thinking laterally). I had the great company of Dr Mukund Thattte, Dr Nitin Mokal, Dr Prashant Govilkar, Dr Milind Wagh, Dr Dean Gomes, Dr Shrirang Purohit, Dr Jyostna Murthy, Dr Uday Bhat and many others, all of whom made my residency there an enjoyable experience (nostalgia)!!!
Incidentally the paper on VAC therapy where I worked with the wall suction unit shows the use of wall suction for applying vacuum as the portable devices were expensive. The only problem was- there is no automatic control of the suction pressure and one has to keep a watch on the pressure and see that it does not accidentally go beyond the set level. If we can attach a pressure regulator that automatically adjusts the pressure then wall suction device would be the most cost effective vac application method.
Year : 2009| Volume : 42 Issue : 2 Page : 161-168 Versatile use of vacuum-assisted healing in fifty patients Ahmad A F, G Alexander, J R Kanjoor.
Indian Journal of plastic surgery
Wound debridement or removal of dead tissue from the wounds is an excellent method that clears up the wound and enhance healing. Once the wound has been cleared of infection and dead tissue, it may need some sort of coverage. Some wounds may need skin grafts to cover the raw areas while others may need more flesh and tissue so that a ‘flap cover’ may be needed.
With all these methods preventing pressure still remains the most important point in avoiding and treating pressure sores+
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