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Fast Fact and Concept #41: Pressure Ulcer Management II: Debridement and Dressings

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Title: Fast Fact and Concept #41: Pressure Ulcer Management II: Debridement and Dressings

Author(s): Charles von Gunten and Frank Ferris

The first step in deciding how to management pressure ulcers is an assessment of whether or not the wound is likely to heal. If the patient has a prognosis of months to years, adequate nutrition, and blood flow to the tissue, then healing is possible. If the patient has a prognosis of days to weeks, anorexia/cachexia, and/or the wound has inadequate perfusion, then symptom control alone is appropriate and uncomfortable/burdensome treatments are not appropriate.

Debridement
Always provide adequate analgesia!!. Necrotic tissue must be removed for ulcer healing; surgical debridement is the fastest and most effective method when there is healthy surrounding tissue. Debridement gels (eg Hypergel, Santyl, Nu-gel) on the ulcer, under an occlusive dressing (such as DuodermDuoDerm), are available for ulcers that don't require surgery or when surgical debridement is incomplete. These products come with or without enzymes to encourage autolytic or enzymatic debridement. For minimally necrotic ulcers, occlusive dressings such as DuodermDuoDerm q week promote autolysis.

A commonly prescribed form of mechanical debridement is the use of saline, wet-dry dressings. This treatment actually retards healing by pulling off new epithelial cells as part of healthy granulation tissue; its use for the treatment of skin ulcers should be abandoned. Note: If the patient is close to dying, and/or the wound will never heal, then debridement should not be attempted.

Dressings
We know that living tissue requires moisture for transport of oxygen and nutrients. A moist ulcer environment promotes the migration of fibroblasts and epithelial cells; growth factors are present in the serous exudate that speed healing. In contrast, a dry environment is conducive to necrosis and eschar. Ulcer healing is delayed iIf there is bacterial infection within the wound bed. Erythema, purulent exudate and fever are signs of infection. Cleansing and application of topical antibiotics may be sufficient for superficial infection with minimal surrounding erythema. Systemic antibiotics are indicated for deep/surrounding tissue infection, or if ulcer healing is delayed. Cleanse wounds that are expected to heal with non-cytotoxic fluids (e.g. saline). Cytotoxic fluids (e.g. betadineBetadine) will kill granulation tissue. Clinical Pearl: don't cleanse an ulcer with any fluid you wouldn't put in your eye if you want the ulcer to heal.

There are 6 classes of dressings distinguished by the wear time and whether you want to add or remove fluid in order to maintain the ideal moist, interactive ulcer-healing environment. A dry ulcer needs to have moisture added through a hypotonic gel (donates water). In a wet exudate, a hypertonic gel or foam is used to remove water.

1. Polyurethane foams (LyofoamLYOfoam, Allevyn, NudermNu-Derm, FlexanFlexzan). Most absorptive. Used under a covering secondary dressing.
2. Alginates (KalostatKaltostat, Sorbsan). Works to desiccate an overly wet wound. Prevents maceration of surrounding skin from excess fluid; is hemostatic and may reduce risk of infection.
3. Hydrogels (IntraSite, ElastoGelElasto-Gel, ClearSite, Aquasorb). Used for wounds with larger volumes of exudate. Require a secondary dressing to secure.
4. Hydrocolloid wafers (DuoDerm, Comfeel, TegabsorbTegasorb, Restore).Self-adhesive. Promotes autolysis, angiogenesis and granulation. Remains in place for 5-7 days. Often used to "seal" a wound that is otherwise clean in order to promote healing. Can also be used to seal an underlying dressing in order to maintain a moist environment in which the wound can heal. Note: do not to use an occlusive dressing if there is a substantial risk of infection.
5. Thin films (OpSite, Tegaderm) For skin at risk or Stage I pressure ulcers. Also to hold another type of absrbentabsorbent dressing in place.
6. Cotton Gauze. Used to cover the primary dressing. Rarely the appropriate dressing for a significant skin ulcer. Note: Saline wet-to-dry dressings are only useful for mechanical debridement.

Also See:
Fast Fact #40: Pressure Ulcer Management: Prevention and Staging

References

Paul Walker. The pathophysiology and management of pressure ulcers. In:Topics in Palliative Care, Volume 3. Eds. Russell K. Portenoy and Eduardo Bruera. Oxford University Press 1998. Pp 253-270.

Paul Walker. Update on pressure ulcers. Principles & Practice of Supportive Oncology Updates 2000;3(6):1-11.

Fast Facts and Concepts was originally developed as an end-of-life teaching tool by Eric Warm, MD, U. Cincinnati, Department of Medicine. See: Warm, E. Improving EOL care--internal medicine curriculum project. J Pall Med 1999; 2: 339-340.

Copyright Notice: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: von Gunten C and Ferris F. Fast Facts and Concepts #41: Pressure ulcer Debridement and dressings, May, 2001. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 5/2001

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)
Training: Fellows, 1st/2nd Year Medical Students, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery
Non-Physician: Nurses

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Skin, Lymphatic


The Fast Facts series is distributed for educational use only and does not constitute medical advice. For the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror version is provided subject to copyright restrictions for educational use within the Inter-Instutional Collaborating Network on End-of-Life Care (IICN).