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Department Name (View Master > Edit Slide 1) Department Name (View Master > Edit Slide 1)

Pressure Injury Surgical

Management and Treatment
Options
Dawn J. Wang, M.D., M.S.
Assistant Professor of Plastic Surgery
Chief of Plastic Surgery, UPMC St. Margaret’s Hospital
Medical Director: UPMC Passavant Wound Healing
Services

6th Annual Current Concepts in Spinal Cord Injury

Rehabilitation
PRESSURE ULCERS
April 24, 2021

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Department of Plastic Surgery Department Name (View Master > Edit Slide 1)

72 y/o Female

19 Oct 2009

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Department Name (View Master > Edit Slide 1) Department Name (View Master > Edit Slide 1)

Cause
Pressure Ulcer

• Significant problem:
– Age >65
– Impaired mobility
– Inadequate nutritional intake
– Critical illness
– Total annual US cost $11 billion
– Associated with impaired health-related quality of
life

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Department Name (View Master > Edit Slide 1) Department Name (View Master > Edit Slide 1)

• Landis, 1930 Complicated Wounds

– Capillary blood pressure, 12 mm Hg on venous
end to 32 mm Hg on arterial end • Acute Wound
– External compression exceeds capillary bed • Chronic wound
pressure, perfusion impaired, ischemia results
– Arrested in one of the stages of wound
healing
– Inflammatory stage most common

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Department Name (View Master > Edit Slide 1) Department Name (View Master > Edit Slide 1)

Wound Healing Reconstructive Ladder

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Department Name (View Master > Edit Slide 1) Department Name (View Master > Edit Slide 1)

Pre-surgical Treatment

• Goals:
– Promote healing in a timely fashion
– Establish clean and healthy wound base
Medical and Surgical – Adequately vascularized
MAXIMIZING OUTCOME – Acute wound

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Department Name (View Master > Edit Slide 1) Department Name (View Master > Edit Slide 1)

Lab Testing Testing as Indicated

• CBC • Iron • ABIs • MRI
• CMP • Ferritin • Toe pressures • Ultrasound
• Albumin • Zinc • Venous reflux • Culture
• Prealbumin • Vitamin D • DVT • Biopsy
• PT/PTT • Urine continine • Xray • Pre-operative
• CRP • Auto-immune labs as • CT clearance

• SED rate indicated

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Department Name (View Master > Edit Slide 1) Department Name (View Master > Edit Slide 1)

Other Considerations Correct medical abnormalities

• Smoking Cessation • Movement • Blood glucose levels
• Pressure – Joints
• Coagulation abnormalities
• Moisture – Tendons
• Improper drug regimens
• Shear • Cavity/bursa
• Exposed structures • Social
• Financial

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Department Name (View Master > Edit Slide 1) Department Name (View Master > Edit Slide 1)

Nutrition Nutrition
1. Albumin 7. Vitamin D
2. Pre-albumin 8. Magnesium
3. A1c 9. Copper
4. Vitamin C 10. Zinc
5. Vitamin A 11. Iron
6. Vitamin E 12. Amino Acids

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Department Name (View Master > Edit Slide 1) Department Name (View Master > Edit Slide 1)

Treatment Goals

• Restore adequate blood flow

• Antibiotics if infection present
• Debride wound aggressively
• 10% to 15% reduction in wound area per
CREATE A PRO-HEALING week
ENVIRONMENT

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Wound Bed Management Debridement

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Department Name (View Master > Edit Slide 1) Department Name (View Master > Edit Slide 1)

Dressing Management Recommended Dressings

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Department Name (View Master > Edit Slide 1) Department Name (View Master > Edit Slide 1)

Cigarette Smoking Adverse Effects of Smoking

• Impairs neutrophils and macrophages • Wound infection: increased risk
• Compromise oxygen delivery
– Reduction of bactericidal actions of neutrophils
– Vasoconstriction

– Displacement of oxygen by CO • Hypoxia: a fundamental mechanism to disrupt

– Increased platelet aggregation and viscosity
acute wound healing
• Entire reparative processes requires normal tissue oxygen • Tissue O2 concentrations: decreased
pressures – After 1 cigarette regardless of smoking history
– Cell migration to wound sites
– “Pack-per-day” smokers
– Bacterial defense
• Tissue hypoxia a significant portion of each day
– Collagen synthesis

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Department Name (View Master > Edit Slide 1) Department Name (View Master > Edit Slide 1)

Smoking and Wound Healing Post-Debridement

• 1ppd = 3x freq of flap necrosis
• Metalloproteinases
• 2ppd = 6x freq of flap necrosis – Destroy naturally produced growth factors

• Nicotine acts via the sympathetic system – Prevent buildup by mechanical removal

– vasoconstriction and limit distal perfusion

• Biofilm of proteinaceous debris
• 1 cigarette = vasoconstriction > 90 min removed at regular wound intervals
• Smoking 10 minutes decreases O2 in the skin 22-48% • VAC
– Decrease proliferation of erythrocytes, macrophages and fibroblasts • Skin substitutes
• High levels of carbon monoxide
– Shifts the oxygen-hemoglobin curve to the left

– Decreased tissue oxygen delivery

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Department Name (View Master > Edit Slide 1) Department Name (View Master > Edit Slide 1)

Vacuum Assisted Closure (VAC) Stimulating a Wound Bed

• Useful post-debridement dressing
– Uninfected
• Topical growth factors
– Well-vascularized • Cultured skin
• Helps keep the wound sterile
• HBO
• Promote formation of granulation
tissue • Any combination of above
– Prevents buildup of proteases and
bacteria

– Decreases peri-wound edema

– Increases local blood flow

• Controls moisture

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Department Name (View Master > Edit Slide 1) Department Name (View Master > Edit Slide 1)

Treatment
• Pressure relief
– Low air loss mattress, Clinatron bed
• Negative pressure wound therapy
• Skin matrices
• HBO if osteomyelitis
• Formal surgical reconstruction SURGICAL WOUND
– 80% chance of lifetime recurrence if underlying TREATMENT
factor not mitigated

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Department Name (View Master > Edit Slide 1) Department Name (View Master > Edit Slide 1)

Poor Candidate for Definite

Bilateral Ischial Wound
Closure
• 24 yo male with tetraplegia secondary to
diving injury as a teenager
• Bilateral ischial pressure ulcers

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Department Name (View Master > Edit Slide 1) Department of Plastic Surgery

Risks

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Department of Plastic Surgery Department of Plastic Surgery

Goals of Surgical Intervention Factors to Improve Outcome

• Restore skin integrity and function • Presence of osteomyelitis

• Elimination of unstable scar tissue • Wound bioburden

• Recontour bony prominences • Nutritional status

• Bowel and bladder management
• Diagnose and treat osteomyelitis
• Spasticity and contracture
• Reduce healing time
• Heterotopic ossification
• Reverse chronic inflammatory and catabolic state
• Comorbid medical conditions
• Prevent secondary amyloidosis and renal failure
• Anesthesia
• Prevent malignant transformation • Previous ulcer surgery
• Improve hygiene and appearance • Urinary tract infection
• Reduce health care costs • Smoking cessation

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Department of Plastic Surgery Department of Plastic Surgery

Autonomic Dysfunction DVT Risk and Prevention

• Anesthesia risk • Consistent with clinical practice guidelines

– Manifests as bradycardia and hypotension • Anticoagulation can increase hematoma risk
or tachycardia and hypertension • Article by Rimler et al. 2011
– Depends on level of injury and if – 5 year, 260 case series
sympathetic tone is preserved – No DVT prophylaxis with chronic SCI
– Paralytic agent succinylcholine should not – Zero incidence of peri-operative DVT
be used: lifetime risk of serious
hyperkalemia

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Department Name (View Master > Edit Slide 1) Department Name (View Master > Edit Slide 1)

Contra-indications

• Active infection or dense biofilm

• Inadequate blood flow
• Necrotic tissue
• Uncontrolled moisture
• Anesthesia risk
• Risks due to post-operative protocols

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Department Name (View Master > Edit Slide 1) Department of Plastic Surgery

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Department of Plastic Surgery Department of Plastic Surgery

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Department Name (View Master > Edit Slide 1) Department Name (View Master > Edit Slide 1)

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Department Name (View Master > Edit Slide 1) Department Name (View Master > Edit Slide 1)

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Department Name (View Master > Edit Slide 1) Department of Plastic Surgery

Bilateral Ischial Wound

• 24 y/o male with tetraplegia secondary to diving injury as a
teenager
• Bilateral ischial pressure ulcers

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Department of Plastic Surgery Department Name (View Master > Edit Slide 1)

Prior to STSG

19 Oct 2009

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Department Name (View Master > Edit Slide 1) Department Name (View Master > Edit Slide 1)

Healed Wound Lower Extremity Flap

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Department of Plastic Surgery Department of Plastic Surgery

Postoperative Care

• Clinatron
• Strict log roll
• 30 degree elevation only for meals
• 3 weeks then Mercy SCI unit for sitting
protocol RESEARCH AND DATA

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Department of Plastic Surgery Department of Plastic Surgery

Conclusions • For QoL assessment, Spitzer recommends at

• Few RCTs evaluating pressure ulcer treatments least 5 aspects:
• Little evidence to justify the use of one vs. another: 1. Physical well-being

– Support surface 2. Social well-being

– Dressing 3. Mental status

– Routine nutritional supplements 4. Severity of systems

– Biological agent 5. Perception of health

– Adjunctive therapies

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Department of Plastic Surgery Department of Plastic Surgery

Effects on Quality of Life

• Few studies related to pressure ulcers and QoL
(Lagemo et al.)
– Interviewed 8 patients; 4 SCI • Retrospective chart review 1997 – 2015
– Averaged 1.5 – 2 hours/day (8% of wakeful hours) thinking
about their wounds (18)
• 276 with flap coverage
– Most could not define the time frame for healing which led to • Overall complication rate: 58.7% (162
frustration, depression and restriction in ADLs. patients)
• Need hope for healing • Wound dehiscence: most common 31.2%

Bamba, R et al.

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Department of Plastic Surgery Department of Plastic Surgery

Complication Risk Factors

Independent risk factors for recurrence
1. BMI <18.5 [relative risk (RR) 3.13]

2. Active smoking [RR 2.33]

3. Ischial pressure ulcers [RR 3.46]

Independent risk factors for wound dehiscence

1. Ischial pressure ulcers [RR 2.27]

2. Pre-operative osteomyelitis [RR 2.78]

Independent risk factor for wound infection

1. Diabetes [RR 4.34]

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Department of Plastic Surgery Department of Plastic Surgery

Intraoperative Specimen Concordance

• Intraoperative culture and histology concordant: 65

cases
– Both positive in 43 cases

– Both negative in 22 cases

• Histiological diagnosis of osteomyelitis with negative

intraoperative culture: 15 cases
• Positive intraoperative culture without histological
evidence: 36 cases
– Positive predictive value (PPV) 54%

– Negative predictive value (NPV) 59%

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Department of Plastic Surgery Department of Plastic Surgery

Swab Cultures Inadequate

• Only 22% concordance between swabs and intraoperative samples
(25 out of 116)
– Yield of different micro-organisms 36% (41 out of 116)

– 27% false negatives (swab negative/intraoperative positive) In summary, given the cumulative
nature of the suboptimal data, we draw
– 16% false positives (swab positive/intraoperative negative
several conclusions:
• Compared to gold standard: swab cultures
• When osteomyelitis is present, we do
– 80% sensitivity
not find data supporting antibiotic
– 54% specificity
therapy in the absence of a plan to
• Conclusion: Not useful to diagnose superinfection or the role of cover the wound. Lacking wound
involved micro-organisms coverage, antibiotic therapy may
• 13% CRE rectal carriers: a marker of antibiotic overexposure offer only a transient response.

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Department of Plastic Surgery Department of Plastic Surgery

Results Limitations
• Pelvic osteomyelitis the primary admission diagnosis for 117 (53%)
• 220 patients included:
• Concurrent febrile urinary tract infection (UTI) in 56 (26%) – 153 (70%) received antibiotics
• Most received osteomyelitis-directed antibiotics (153; 70%) – 113 wound documentation
• 55 (25%) had surgical procedure – 113 microbiology results
• 48 (22%) received a combined medical-surgical approach
– 64 swab wound cultures
• 7 of 55 (12.7% of those who had a surgical procedure) also received
a myocutaneous flap coverage – 40 had NO culture
• Almost 1/3 of all patients had 2 or more readmissions within a
– 33 (29%) of patients had a negative culture
year
• Patients treated with medical-surgical approach less likely to be – 23 (11%) gold standard bone culture/biopsy
admitted
• 12 of 23 bone cultures were positive for an organism

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Department of Plastic Surgery Department of Plastic Surgery

Questions?

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PM&R Role in Pre- and Post-op Wound
Management
Jessica Berry, MD
Assistant Professor, Physical Medicine and Rehabilitation
University of Pittsburgh
Spinal Cord Injury Rehab Medicine
 Objectives
• Review post-flap management and necessary equipment
• Review progressive sitting protocol
• Understand SCI sequelae and management in relationship to
wound risk/wound healing
 Post-Flap Management
• Strict bed rest
• Positioning
– Supine
– Prone
• 2-8 weeks (as determined by physician team)
– Allows for development of adequate tensile strength for the wound
 Post-Flap Management
• Air-fluidized bed
• Limit leg range of motion
– May initiate PROM once healed
– Don’t initiate sitting protocol until hip ROM at 90 without stress to surgical site
• Limit head elevation
– 15-30 degrees max
• Treat spasticity
– May cause dehiscence
 Where to?
• Post-flap options
– Remain in acute care hospital
– Discharge home
– Discharge to skilled nursing facility
 Progressive Sitting Protocol
• Inpatient rehabilitation setting
• Considered standard of care
– Supported by SCI Clinical Practice Guidelines
• Little evidence to support a particular protocol
• General concept is progressive mobilization after flap site is well healed
• Must include
– education to prevent recurrence
– evaluation for modifiable factors that contributed to initial breakdown
 Progressive Sitting Protocol
• The flap site is examined pre- and post- each period of sitting to monitor
integrity of the flap
– Looking for dehiscence, erythema, bruising
• If at any point, there is concern for breakdown of flap site, the sitting
protocol is put on hold for at least one day
– If held, the protocol will resume at the previous time increment
• Entire protocol takes approximately 12-14 days
Initial sitting protocol
• Power wheelchair
• Recline to 70 degrees
• Hoyer lift for all transfers
• Air-filled villous cushion
• Air-fluidized bed
 Daily Progression of Sitting

15 min BID 30 min BID 45 min BID 1 hour BID

1 hour, 15 min 1 hour, 30 min 1 hour 45 min

2 hours BID
BID BID BID

3 hours BID 4 hours BID

2 hours, 30 min
• (3 hours, 30 min • May extend to 5
BID BID may be added) hours BID
 At 2 hours BID…
• Switch patient to their regular wheelchair
– at their regular angle or tilt/ recline
• Switch patient to low air loss mattress, or the mattress they will use at
home
• Remove sutures from flap site (per surgeon)
– may be gradual over a period of 1-3 days
• Perform pressure mapping and consider alternative cushions
 Patient Education
• Goal is to prevent recurrence
– Etiology and risk factor education
– Basics of prevention and treatment
– Bed repositioning/safe transfer techniques
– Daily skin inspection
– Keep moisture at a minimum
• Tobacco Cessation
• Nutrition
 Medical Management Before/During/After
Sitting Protocol
• Neurogenic bowel and bladder management
• Spasticity management
• Pain
• Heterotopic ossification
• Autonomic dysreflexia
• Orthostatic Hypotension
• Nutrition
 Neurogenic bowel and bladder
• Bowel • Bladder
– Prevent incontinence – Prevent incontinence
– May require ostomy pre-op – Permanent or temporary indwelling
– Formal bowel program catheter
– Considerations – Intermittent catheterization
• Dietary changes – Considerations
• Mobility changes • Change in necessary frequency
• Commode use • Medications
• spasticity
• AD risks
 Spasticity Management
• Pre- and post-op
• may be worsened by presence of wound/surgery
• can negatively impact skin integrity/pressure/wound healing
• Goals
– Prevent wound dehiscence/formation of new wounds
– Allow appropriate positioning
– Prevent/correct contracture
– Minimize discomfort
 Spasticity Management
• Medications
• Neurotoxin injections
– Timing considerations in conjunction with flap surgery
• Intrathecal baclofen
• Surgical contracture release
 Pain
• Potential increase in neuropathic pain due to noxious stimulus
of wound/surgery
• Risk for AD
– May consider empiric tx of potential pain
• May contribute to spasticity
 Heterotopic Ossification
• Implications for positioning,
ROM, pressure
• Identification and consideration
of tx prior to definitive wound
surgery
• Treatment options limited
 Autonomic Dysreflexia
• SCI levels T6 and above
• Sympathetic overdrive due to underlying noxious stimulus
• SBP > 20mmHg above baseline
• Monitor and treat as needed (SBP >150 requires medication)
• Optimize management of pain, spasticity, positioning, etc
• May be a sign that positioning not optimal
 Orthostatic Hypotension
• Common in all SCI (higher incidence with higher injury level)
• Increased risk after prolonged bedrest
• Gradual position changes
• Compression when out of bed
• Medications if needed
 Nutrition
• Dietician consult/input in IPR
• Prealbumin monitoring
• Protein supplementation
– arginine
• Vitamin supplementation
 Discharge considerations
• Patient/family education
• Potential changes in functional level, equipment needs,
transfer technique
• Medication and Equipment ordering
• Follow-up plans
Therapy Perspective
Rachel M. Hibbs, DPT, NCS, ATP Pressure Ulcer Prevention,
Assistant Professor, University of Pittsburgh School of Health Healing, and Long-Term
and Rehabilitation Science, Dept. of Rehabilitation Science Management
and Technology
Initial Assessment
• Risk level
• Current wound
• Size
• Stage
• Drainage
• Location
• Equipment
• Bracing or worn medical devices
• Functional status
• Spasticity
• ROM Restrictions
• Posture
• Any medical, seating, or other changes
How is pressure assessed?
Hand Check
• No equipment required
• Quick and easy
• No feedback for education
Pressure mapping
• Equipment required
• Visual Feedback
• Quantitative
HVES (HVPC) for Wound Healing

• Potential Effects
• Decreased healing time
• Increased collagen synthesis
• Increased wound tensile strength
• Increased rate of epilthelialization
• Enhanced bactericidal effects
HVES (HVPC) for Wound Healing
• High Volt Pulsed Current
• Pulse rate: 100-128 pps
• Intensity: 100-150 v
• Duration: 60 minutes
• Frequency 5-7 days/week
• Negative polarity- increase
fibroblast activity and capillary
density
• Positive polarity- increase
epidermal resurfacing
• Precautions
• Untreated osteomyelitis
• Exposed bone
• Additional precautions for all
types of stimulation:
• Malignant tissue
• Pacemaker
• Near or crossing reproductive organs
Sitting Protocol Considerations
• Activities while on bedrest: eating, hygiene, positioning for work or entertainment
activities
• 70 degrees hip flexion (110 degrees recline)- is driving safe?
• Upper extremity overuse/positioning
• Slow progression to functional activities
• Baseline seated posture and functional status may be unrealistic post-flap
• Reconditioning: cardiovascular and neuromuscular/musculoskeletal concerns
 • May need specialty mattress or bed
Offloading • Prone positioning if possible
considerations • Explore positions of comfort and pressure relief
Cushion Considerations
• Round table session for more detail
• Custom options
• Refer for pressure mapping
Cushions for alternative seating surfaces
Consider all surfaces: toilet, shower chair, vehicle, floor
“Creative” methods of offloading after healing
Pressure relief: How?
When?

• Methods of pressure relief

• Evidence for frequency and duration
• Positioning during pressure relief
• Memory Seating and Virtual Seating Coach
• Electronic Aids
• Creative methods of pressure relief (leaning on
surface, against wall)
High- and Low-Tech Memory Aids
• Timer, watch/phone alarms
• Apps
• Seating Coach
Resources

• PVA Clinical Practice Guidelines

• Pressure Ulcer Prevention and
Treatment
• SCI Model Systems Knowledge
Translation
• Factsheets: Skin Care and
Pressure Sores
• United Spinal Association
• Resource Center
Referrals
• Smoking cessation
• Nutritional considerations
• Center for Assistive Technology
• https://www.upmc.com/services/rehab
/rehab-institute/services/cat