The choice of a plastic surgery method for the pressure ulcer of the greater trochanter of the femur in patients with spinal injury

There are three constants in life ... change, choice and principles. —Stephen Covey Plastic and reconstructive surgeons maintain the broadest scope of practice among their surgical colleagues, operating from head to toe on patients of all ages. Encountering a unique spectrum of functional and cosmetic concerns on a daily basis, plastic surgeons rely on overarching principles rather than absolutisms to guide their practice. First described nearly five centuries ago, the principles of plastic surgery remain paramount to operative success today; while adhering to central tenets of reconstruction, the modern surgeon relies on an intimate knowledge of native anatomy and technical finesse to restore form and function. Frenchman Ambroise Paré was, to our knowledge, the first to define a set of reconstructive surgical principles, outlining five central tenets in 1564.1 Building on these, Millard reported on his mentor Sir Harold Gillies' "ten commandments of plastic surgery" in 1950,2 codifying a set of principles encompassing practical, technical, and ethical axioms to guide the reconstructive efforts of plastic surgeons (Table 1). Millard later expanded on these commandments to define 33 fundamental principles of plastic surgery in his report Principlization of Plastic Surgery, categorizing each as either a preoperational, executional, innovational, contributional, or inspirational principle.1,3 Table 1. - Principles of Plastic Surgery by Paré and Millard/Gillies Paré (1564) 1. Take away what is superfluous. 2. Restore to their places things which are displaced. 3. Separate tissues which are joined together. 4. Join those tissues which are separate. 5. Supply the defects of nature. Gillies/Millard (1950) 1. Thou shalt make a plan. 2. Thou shalt have a style. 3. Honor that which is normal and return it to normal position. 4. Thou shalt not throw away a living thing. 5. Thou shalt not bear false witness against thy defect. 6. Thou shalt treat thy primary defect before worrying about the second one. 7. Thou shalt provide thyself with a lifeboat. 8. Thou shalt not do today what thou canst put off until tomorrow. 9. Thou shalt not have a routine. 10. Thou shalt not covet thy neighbor's plastic unit, hand- maidens, forehead flaps, Thiersch grafts, cartilage nor anything that is thy neighbor's. As with any principles, Gillies' ten commandments merit a revisit. Most ring true today, each contributing to a cohesive narrative: plan ahead, but remain flexible; focus on the task at hand, but always be thinking about what's down the road; restore normal anatomy, while respecting that you will often create abnormal anatomy in the process. Although we are not in agreement regarding putting off all that one is able to until tomorrow, the remainder of these principles bear relevance to the practice of plastic surgery nearly 70 years after their definition. Knowledge of anatomy, the reconstructive ladder, surgical planning, and the need for foresight are all components of modern surgical education. Many have written on surgical technique in plastic surgery4,5; however, few have attempted to consolidate this information into a series of operative principles. In addition to the general principles previously outlined, we offer 15 fundamental operative principles that we believe are broadly applicable to the practice of plastic surgery today. THE 15 FUNDAMENTAL OPERATIVE PRINCIPLES OF PLASTIC SURGERY Principle 1: Plan Carefully and Precisely before You Operate Although some decisions must be made intraoperatively, the majority of one's surgical planning should be performed before the procedure. This is not unlike knowing one's final destination, and mapping the course to get there. The operative plan should also include a backup plan: one can never predict whether and when the primary plan might fail or need alteration.6 Attention to detail preoperatively prevents wasting precious time in the operating room and is safer for the patient. Principle 2: Ensure That Your Operative Goals Are in Alignment with the Patient's Preoperatively Use your time from the initial consultation to the day of surgery to define and articulate the patient's goals, and find common ground on what can be achieved reasonably. Focus on the patient's top three goals or concerns that he or she wishes to address, and be honest with the patient and yourself about the limitations. Note the patient's goals in the chart explicitly as they are articulated, and let these goals guide your operative plan. Establishing open communication and clear expectations is key to gaining happy and satisfied patients. Ask the patient immediately preoperatively to reiterate the top three goals that must be achieved for him or her to be happy or consider the operation to be a success. Principle 3: When in Doubt, Don't Hesitancy regarding whether to perform a procedure or make some kind of change in the operating room usually stems from some subconscious warning that what you are considering is not the right thing to do. Let your training, experience, and expertise guide you: when in doubt, don't. Always side with patient safety, as you never want to risk a patient's care, life, or outcome. Principle 4: Incise Skin under Tension, and Close with No Tension Measure twice and incise once. When incising the skin, do so under tension, which allows for more precision, and minimizes tissue trauma and the need to connect multiple shorter hesitation cuts. Sometimes it is difficult, inconvenient, or ergonomically awkward to incise under tension. Stop; readjust your position, retractors, or your assistant; and incise the tissue precisely. Precision in this step sets you up for success in the ensuing portions of the operation. Reapproximate the skin edges with minimal to no tension after a layered closure. This is a fundamental principle in plastic surgery, which contributes to optimal wound healing and final scar appearance. Address dog-ears in the operating room, as they rarely subside. The sole exception may be a dog-ear in the scalp masked by hair that may subside in the long term. Principle 5: Close Wounds in Layers, and Approximate Wound Edges Meticulously Skin closure is ultimately the only part of your work that the patient sees directly. Close wounds meticulously and in layers to optimize wound healing.7 Use pear-shaped deep layer sutures (fascia or dermis only) to minimize any tension on your skin closure. Approximate but do not strangulate wound edges with slight eversion. In most cases, simple yet carefully placed interrupted sutures achieve an appropriate amount of tissue eversion. Overeversion of wound edges does not necessarily produce better cosmesis and can be problematic. Precise approximation of the wound edges with uniformity and without palpable edges or irregularities yields optimal outcomes. Remember that 90 percent of how a patient heals is genetic, and 10 percent is the closure and thus dependent on the surgeon's skill—we can all appreciate how much that 10 percent contributes to the final outcome. Principle 6: Close Dead Space Closing dead space is important in all of surgery; however, it is exceptionally important in plastic surgery. This principle aids in the prevention of hematomas, seromas, and other collections, and optimizes wound healing by avoiding undue tension. This is particularly important in precision procedures such as a rhinoplasty or face lift. When in doubt, use a drain to evacuate fluid from dissected tissue planes and encourage tissue adherence. Focus on closing dead space before complications and undesirable outcomes force you to later. Principle 7: Respect the Soft Tissue and Visualize the Tissue Planes Handle tissue gently, and always be mindful of how you treat the soft tissues. Rough handling can damage soft tissues and impair wound healing, so be mindful of how much tension is on your retractors, or how hard you are squeezing the skin between your forceps. Minimizing tissue trauma will optimize wound healing and contribute to better outcomes. Furthermore, when dissecting in tissue planes or elevating flaps, be precise and maintain the appropriate plane. This involves appropriate exposure with the right retractors so that the surgeon can focus on cutting precisely while the tissue is under tension. Operative approaches that allow for safe access to underlying structures have been described; however, the safety of each approach is reliant on dissecting within a known plane.8 Principle 8: Achieve Meticulous Hemostasis and Irrigate the Wound before Closure Obtain meticulous hemostasis at the end of your procedure. This is essential for minimizing postoperative complications and optimizing wound healing. Close the skin with the patient normotensive to identify any additional areas requiring coagulation. When in doubt, use a drain to maximize tissue layer adherence and diminish early postoperative swelling and bruising. Remember, drains do not prevent hematomas, but meticulous hemostasis does. Irrigation of the wound following meticulous hemostasis will aid in the removal of any residual debris, and potentially identify residual bleeding that may require further hemostasis. Principle 9: Repeat and Refine Your Technique Continuously—Being Self-Critical Is Essential to Becoming an Expert Repetition is essential to technical refinement and innovation—but change and refinement are essential to avoid complacency in technique.9 Continue asking how an operation can be performed better. Ensure that your operative procedure is not limited by your knowledge alone—study the masters of individual techniques to develop a deeper understanding.10 Even Michelangelo, recognized for his artistic mastery at age 14, selected a mentor who pushed him to improve his technique and evolve as an artist over the course of his career.11 Engaging with other talented plastic surgeons in an open forum is also crucial to becoming a master. Present your work and your results honestly, and accept criticism with an open mind. At the highest level, ego is often what holds one back from achieving his or her best possible results. Those who remain humble and honest will rise above the rest. Principle 10: Missteps in Plastic Surgery Are Unforgiving Many procedures in plastic surgery are operations of millimeters. Even the smallest errors can have catastrophic consequences; thus, meticulous attention to detail is essential in both cosmetic and reconstructive plastic surgery. Remember, revision procedures are exponentially more difficult and more challenging. Appropriate planning and execution will facilitate the avoidance of missteps. Do everything you can to get it right the first time. Principle 11: Just Because You Can Doesn't Mean You Should Plastic surgeons must use their best discretion in determining "how much," "how big," or "how far." Should more skin be resected? Add more tip projection? Use larger implants? Just because you can, doesn't mean you should (Rohrich et al., in press). Consider all aspects of the decision, and always use your best judgment to do what's right for the patient. Principle 12: If It Doesn't Look Good on the Operating Table, It Won't Look Any Better Later In most reconstructive and cosmetic plastic surgery procedures, the result you see on the operating table is about as good as you can expect later after the resolution of swelling. Make sure that you are happy with your result before concluding the procedure, as one can never rely on the assumption that the result will improve postoperatively. Never leave the operating room unless the result is as good as it can be with your very best effort. Plastic surgery is not a race or a timed event; however, optimal preparation allows for proper sequencing to maximize intraoperative effort and time. Principle 13: Apply Dressings Meticulously Dressings are often the only thing visible to a patient or his or her family following a procedure. Messy dressings, regardless of how fastidious you might have been in the operating room, convey sloppiness and lack of attention to detail to those who see them. Ensure that dressings and incisions are clean, and if possible, remove all blood stains before the family sees the patient. An extra minute or two spent dressing surgical wounds postoperatively can make a considerable difference in the perceived outcome. Principle 14: Keep the Patient's Family Informed during and after Surgery The circulating nurse should update the family hourly during the procedure so that they know that their family member is safe. After concluding the procedure, speak with the family in a timely manner to let them know how the procedure went. Maintaining this line of communication is an essential component of the trust that exists between the surgeon and the patient/families under his or her care. Principle 15: Underpromise and Overdeliver—Honesty Is the Best Policy In life and in plastic surgery, always underpromise and overdeliver. We live in a digital era where anyone can be famous on the Internet.12,13 Although many promote their own celebrity on their Web sites or social media platforms,14–17 you must be honest with yourself and the patient when it comes to what you can do, and more importantly, what you cannot do. You are a surgeon, not a magician, and you operate with a scalpel, not a wand. Advise your patient that you will do your very best, but can never guarantee a result.18 Furthermore, medicine and plastic surgery demand the utmost honesty and integrity. Honesty and integrity will gain the confidence of your patients and colleagues alike. Although nothing can guarantee success in plastic surgery (see principle 15), adhering to these principles will guide you along the path to success. Remember how privileged we are to care for our patients, and relish the opportunity to help those who cannot help themselves. It is right that we should stand by and act on our principles; but not right to hold them in obstinate blindness, or retain them when proved to be erroneous. —Michael Faraday

Wound Healing Society 2015 update on guidelines for pressure ulcers.

1. Co-chaired this panel 2. University of Washington, Seattle, WA 3. University of Texas Medical Branch Galveston, Galveston, TX 4. Sinai Hospital, Baltimore, MD 5. Johns Hopkins Medical Institutions, Baltimore, MD 6. University of Southern Denmark, Odense University Hospital, Odense, Denmark 7. University of South Florida, Tampa, FL 8. University of Virginia Health System, Charlottesville, VA 9. St. Louis Medical Center, St. Louis, MO, and 10. University of San Francisco, San Francisco, CA

Plastic Surgeonsʼ Performance during the February 27 Earthquake in Chile

The benefits of nutritional interventions with various compositions for pressure ulcer prevention and treatment are uncertain. There may be little or no difference compared to standard nutrition or placebo. Nutritional supplements may not increase gastrointestinal side effects, but the evidence is very uncertain. Larger studies with similar nutrient compositions would reduce these uncertainties. No study investigated the effects of special diets (e.g. protein-enriched diet, vegetarian diet) on pressure ulcer incidence and healing.

Quality Indicators for Assessing Care of Vulnerable Elders16 October 2001Quality Indicators for Prevention and Management of Pressure Ulcers in Vulnerable EldersFREEBarbara M. Bates-Jensen, PhD, RN, CWOCNBarbara M. Bates-Jensen, PhD, RN, CWOCNFrom University of California, Los Angeles, Los Angeles, California; and the Borun Center for Gerontological Research, Los Angeles, California.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-135-8_Part_2-200110161-00014 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Pressure ulcers can lead to pain, disfigurement, and slow recovery from comorbid conditions. They interfere with activities of daily living, predispose to osteomyelitis and septicemia (1), and are strongly associated with longer hospital stays and mortality. Frailty and chronic illness, both common among older adults, predispose to pressure ulcers (1–3).The prevalence of pressure ulcers is 10% to 14% among hospitalized patients of all ages (4, 5) and up to 24% among patients in nursing homes (2). One goal of Healthy People 2010 is to reduce the prevalence of pressure ulcers in nursing home patients by 50% (6). Prevention and treatment of pressure ulcers are an important aspect of care for vulnerable elders. This paper presents quality indicators for the prevention and care of pressure ulcers among vulnerable elders and the evidence supporting these indicators.MethodsThe methods for developing these quality indicators, including literature review and expert panel consideration, are described in detail in another paper in this issue (7). For pressure ulcers, the structured literature review identified 177 titles, from which abstracts and articles that were relevant to this report were identified. Fifteen potential quality indicators were proposed on the basis of the literature and the author's expertise and files from previous reviews of the subject (8, 9).ResultsOf the 15 potential quality indicators, 10 were judged to be valid by the expert panel and 1 additional indicator was created by the panel (see the quality indicators). One indicator was merged with an accepted indicator, and 4 were not accepted. The literature supporting each of the indicators judged to be valid by the expert panel process is reviewed below.Quality Indicators 1 and 2: Pressure Ulcer PreventionRisk AssessmentIF a vulnerable elder is admitted to an intensive care unit or a medical or surgical unit of a hospital and cannot reposition himself or herself or has limited ability to do so, THEN risk assessment for pressure ulcers should be done on admission BECAUSE risk assessment can predict pressure ulcer formation in such high-risk groups and forms the basis for intervention.Positioning Needs and Pressure ReductionIF a vulnerable elder is identified as at risk for pressure ulcer development or a pressure ulcer risk assessment score indicates that the person is at risk, THEN a preventive intervention addressing repositioning needs and pressure reduction (or management of tissue loads) must be instituted within 12 hours BECAUSE reduction or elimination of risk factors can prevent pressure ulcer formation.Supporting Evidence. Several cohort and prospective studies and various expert groups provide evidence supporting timely risk assessment. Braden and Bergstrom (10) studied the predictive validity of risk assessment for pressure ulcers in 102 newly admitted nursing home residents. Using the Braden Scale (Figure) with a cutoff score of 18, they demonstrated that the sensitivity, specificity, positive predictive value, and negative predictive value of the admission assessment for subsequent development of pressure ulcers were 75%, 59%, 41%, and 86%, respectively. Of the 28 residents who developed pressure ulcers, the ulcer developed within about 2 weeks after admission in 71%, and all ulcers developed less than 4 weeks after admission (10).Figure. The Braden Scale for predicting risk for pressure ulcers. Download figure Download PowerPoint A multisite cohort study of 843 patients who were followed for 4 weeks found that the Braden Scale was predictive of pressure ulcer development in tertiary care centers, Veterans Affairs medical centers, and skilled nursing facilities (11). As part of the study, prescription of preventive interventions for turning and pressure reduction were evaluated in all three health care settings. Regardless of setting, turning schedules and pressure reduction were prescribed less frequently (7.7% and 34%) for patients at no risk or low risk (Braden Scale scores ≥ 16) than for patients at moderate or high risk (Braden Scale scores ≤ 15; 51% and 69%) (12). In another prospective cohort study of 200 newly admitted nursing home residents, the best predictor of all stages of pressure ulcer formation was Braden Scale score (13). Other investigators also found an association between preventive interventions and Braden Scale scores, in particular the subscale scores for mobility, friction, and shear (14). Prevention interventions are ordered and seem to be used more frequently for people with high-risk Braden Scale scores. However, data showing the effectiveness of the interventions themselves are lacking. Various expert groups, including the National Pressure Ulcer Advisory Panel (NPUAP) (15), the Agency for Health Care Policy and Research (AHCPR) Panel for Prevention and Prediction of Pressure Ulcers (2), and the American Medical Directors Association (AMDA) (3) recommend performing risk assessment in persons who cannot reposition themselves or have limited ability to do so.Quality Indicator 3: Pressure Ulcer PreventionNutritionIF a vulnerable elder is identified as at risk for pressure ulcer development and has malnutrition (involuntary weight loss of ≥ 10% over 1 year or low albumin or prealbumin levels), THEN nutritional intervention or dietary consultation should be instituted BECAUSE poor diet, particularly low dietary protein intake, is an independent predictor of pressure ulcer development.Supporting Evidence. Studies have shown a relationship between risk factors for malnutrition, such as involuntary weight loss, anorexia, gastrointestinal illnesses, cancer, low caloric intake, and low albumin level and pressure ulcer formation; some studies have found a relationship between ulcer severity and severity of malnutrition (16–18). Furthermore, several studies have shown associations between low serum albumin level and the presence (19, 20), severity (17, 18), and healing (21, 22) of pressure ulcers. Other measures of nutritional status, such as body weight, have been shown to correlate with presence (19, 20) and severity (17) of pressure ulcers. Although no direct evidence shows that adequate nutrition will prevent ulcers, these studies provide indirect evidence that prevention of malnutrition will reduce risk for pressure ulcer formation.Quality Indicator 4Pressure Ulcer EvaluationIF a vulnerable elder presents with a pressure ulcer, THEN the pressure ulcer should be assessed for location, depth and stage, size, and presence of necrotic tissue BECAUSE baseline assessment guides interventions, provides data for later comparison to evaluate healing, and can help predict time to healing.Supporting Evidence. No controlled trials of assessment of pressure ulcers have been done, and some experts believe that such studies may be impractical or irrelevant [23]. Several sets of guidelines support formal assessment of pressure ulcers, with documentation of findings, and focus on wound characteristics as a useful method for evaluating and documenting healing. The NPUAP suggested that 1) assessment should include multiple characteristics; 2) pressure ulcer staging is useful for diagnostic purposes only; and 3) size and stage are insufficient measures of healing and, although important, should be used in conjunction with assessment of other wound characteristics (24). Others have also acknowledged the role of assessment in planning and evaluating therapy (3, 25, 26).Observational data support these consensus statements and suggest that many wound characteristics are important predictors of healing or determinants of interventions.Wound Depth and StagePressure ulcers are commonly classified according to staging systems based on the depth of tissue destruction. Stage 1 lesions are least severe, and stage 4 are most severe. Staging systems are best used to diagnose wound severity and show a relationship to healing outcomes, but they do not facilitate monitoring of healing over time (2, 24, 26, 27). Full-thickness wounds (stage 3 and stage 4) generally take longer to heal than partial-thickness wounds (stage 2) (28). A prospective study showed that stage 2 pressure ulcers were 5.2 times more likely to heal than stage 4 pressure ulcers (29). Several other prospective studies also found that wound depth was a predictor of healing and time to healing (21, 30). Two retrospective studies demonstrated that wound depth was related to healing characteristics (31) and that change in depth was related to healing time (8), yet both studies found that initial wound depth did not correlate with healing.SizeSeveral studies have demonstrated a relationship between wound surface area and time to complete healing. In a prospective study to determine progress of healing within specific time frames, van Rijswijk (32) examined the characteristics of full-thickness pressure ulcers in 119 patients (48 of whom had full-thickness ulcers) who were seen in diverse settings. Healing was measured by using surface area tracings, with follow-up of 15 months. Mean reduction in wound surface area for ulcers that healed versus those that did not was significant at 2 weeks (45% vs. −3%) and at 4 weeks (77% vs. 18%). In a secondary analysis of full-thickness pressure ulcers, only 25% healed completely within 50 days, but three quarters had 50% reduction in surface area within 39 days (33). Ulcers with a surface area decrease of at least 39% after 2 weeks healed more quickly than those with a lesser decrease in surface area (median time to healing, 53 vs. 70 days). Retrospective studies also support the relationship between early reduction in surface area and shorter time to healing (8, 31).Presence of Necrotic TissueWound bed characteristics determine treatment options (8, 34). Several studies have shown that replacement of necrotic tissue with granulation and epithelial tissue is indicative of healing (32), and the presence of necrotic tissue at baseline is associated with slower healing (35).Other Characteristics and Assessment ToolsResults of studies of other wound characteristics, such as exudate and undermining, in relation to healing time have been inconclusive (8, 21, 33–36). Nonetheless, assessment is recommended because it can guide treatment (8).Use of a standardized instrument or tool for assessment and documentation of pressure ulcers, such as the Pressure Sore Status Tool (37) or the Pressure Ulcer Scale for Healing (36), is suggested, but no study has examined the effect of standardized evaluation and documentation on pressure ulcer outcomes.Quality Indicators 5 and 6Management of Full-Thickness Pressure UlcersIF a vulnerable elder presents with a clean full-thickness pressure ulcer and has no improvement after 4 weeks of treatment, THEN the appropriateness of the treatment plan and the presence of cellulitis or osteomyelitis should be assessed BECAUSE clean full-thickness pressure ulcers should show evidence of healing or improvement within 4 weeks and lack of improvement should stimulate a change in approach.Management of Partial-Thickness Pressure UlcersIF a vulnerable elder presents with a partial-thickness pressure ulcer and has no improvement after 2 weeks of treatment, THEN the appropriateness of the treatment plan should be assessed BECAUSE partial-thickness pressure ulcers should show evidence of healing or improvement within 2 weeks and lack of improvement should stimulate a change in approach.Supporting Evidence. No direct evidence indicates that reassessment of nonhealing ulcers will improve outcomes. However, it is logical that reassessment is a necessary first step to identify causes of and, hence, treat nonhealing ulcers.These two quality indicators are supported by evidence on rate of healing and healing outcomes from several studies. A randomized, controlled trial involving 85 patients found that up to 42% of stage 2 ulcers healed within 30 days and 75% healed within 60 days, whereas only 17% of stage 3 and 4 ulcers healed within 60 days (30). Similar outcomes were noted in a prospective cohort study of 89 nursing home residents with stage 2 or greater pressure ulcers. After 6 weeks of follow-up, 65% of stage 2 ulcers, 14% of stage 3 ulcers, and no stage 4 ulcers healed (29). In Brandeis and colleagues' (28) cohort study of 1626 patients with a stage 2 or greater pressure ulcer who were admitted to 1 of 51 nursing, up to 54% of stage 2 ulcers healed in 3 months and 74% healed in 6 months (28). Healing rates for stage 3 and 4 ulcers were slower; 31% and 23% healed in 3 months and 59% and 33% healed in 6 months, respectively. Data from a randomized, controlled trial (35) indicated much faster healing times for stage 2 ulcers and provide primary support for the 2-week time frame for the partial-thickness quality indicator: The median healing time was 9 to 11 days, and three quarters of the ulcers healed within 14 to 26 days, depending on topical treatment.In a retrospective study of 143 pressure ulcers, change in surface area at 1 week was a strong predictor of time to 50% healing. The median time to 50% healing among ulcers at all stages that had decreased surface area within 1 week was 21 to 26 days; in contrast, wounds with no change in surface area reached 50% healing in a median of 34 days (8), and an increase in surface area at 1 week was predictive of nonhealing.Reported mean or median times to healing are 8.7 to 38 days (22, 30, 35) for partial-thickness stage 2 ulcers; full-thickness stage 3 or 4 ulcers will heal after 8 to 10 weeks of therapy in 10% to 40% of patients (28, 32). Some investigators have shown that the percentage reduction in surface area after 1, 2, or 4 weeks of treatment is predictive of time to healing (8, 33). The basis for the 4-week timeframe in the full-thickness quality indicator is primarily supported by van Rijswijk and Polansky's study of full-thickness pressure ulcers and percentage reduction in surface area as predictors of time to healing (33).Quality Indicator 7Pressure Ulcer DebridementIF a vulnerable elder presents with a full-thickness sacral or trochanteric pressure ulcer covered with necrotic debris or eschar, THEN debridement by using sharp, mechanical, enzymatic, or autolytic procedures should be done within 3 days of diagnosis BECAUSE dead tissue is a physical obstacle to healing tissue and provides a medium for bacterial invasion and proliferation, which places the patient at high risk for wound infection.Supporting Evidence. Wound debridement can be performed by using sharp, mechanical, enzymatic, or autolytic methods. Sharp debridement involves use of a scalpel, scissors, or other sharp instrument to remove nonviable tissue. One multicenter trial of the effects of a topical growth factor versus placebo on wound healing in 118 patients noted incidentally that sharp debridement was positively associated with healing of diabetic ulcers (38). In this study, all patients received sharp debridement initially and then as needed throughout 20 weeks of follow up. In post hoc analysis, centers that used sharp debridement more frequently (debridement at up to 87% of visits) produced better healing rates (up to 83%) than did centers that used sharp debridement less often (debridement at 15% to 43% of visits; up to 64% healed). Sharp debridement can be safely performed in a fairly aggressive manner at the bedside in a sequential fashion (daily or every other day) by various health care providers. Attention to patient comfort is recommended (systemic or topical analgesia), and some have suggested benefits to combining bedside sequential sharp debridement with other forms of debridement to maximize response (39).Mechanical debridement involves the use of wet-to-dry dressings, whirlpool, or lavage or wound irrigation. The AHCPR panel recommended cautious use of mechanical wet-to-dry dressings for debridement because removal of dressing may cause trauma to new granulation and epithelial tissue. Because debridement with wet-to-dry dressings is painful, the AHCPR panel recommends pain management, such as administration of a systemic analgesic before dressing removal (25). Coarsely woven gauze or cotton sponges appear to be more effective than finer materials in mechanical debridement (40).Enzymatic debridement involves applying a concentrated, commercially prepared enzyme to the surface of the necrotic tissue, with the expectation that it will aggressively degrade necrosis by digesting devitalized tissue. A randomized, controlled trial of enzymatic debridement for necrotic wounds reported a mean time of 8 days to debride stage 4 pressure ulcers with an amorphous hydrogel dressing and a mean time of 12 days for debridement with an enzymatic preparation containing streptokinase and streptodornase (41). These times did not differ significantly, suggesting that an agent with enzyme activity was unnecessary.Autolytic debridement is use of the body's own mechanisms to remove nonviable tissue. Maintaining a moist wound environment allows collection of fluid at the wound site, which allows enzymes within the wound to digest necrotic tissue. Autolytic debridement, which typically involves adequate wound cleansing to wash out partially degraded nonviable tissue, is more effective than wet-to-dry gauze dressings because it removes only necrotic tissue and therefore protects healthy tissues (42–44). Mulder and colleagues (42) evaluated 16 patients in a randomized, controlled trial of a hypertonic hydrogel versus wet-to-dry gauze for wound debridement (the hypertonicity of the gel assists with autolytic debridement by pulling fluid into the area through osmotic forces) (42). The results suggested that the hydrogel could safely facilitate removal of dry adherent eschar from wounds. Other investigators also have found amorphous hydrogels to be effective in removing necrotic debris from wounds (43–45).Quality Indicator 8Pressure Ulcer Management: CleansingIF a vulnerable elder has a stage 2 or greater pressure ulcer, THEN a topical antiseptic should not be used on the wound BECAUSE topical antiseptics may harm the healthy wound bed.Supporting Evidence. No controlled trials have examined the effectiveness or safety of wound cleansing. Contraindications to the use of antiseptic and antimicrobial solutions for cleansing clean pressure ulcers are based on several laboratory studies (46–49). Two studies tested antimicrobial wound cleansers and solutions for toxicity to polymorphonuclear leukocytes. Results showed that even serial dilutions of the products diminished the viability and function of polymorphonuclear leukocytes; in contrast, nonantimicrobial solutions did not cause substantial toxicity to polymorphonuclear leukocytes (46, 47). On the basis of early animal model studies (48, 49), the AHCPR guidelines recommend normal saline as the preferred cleanser because it is noncytotoxic (25).Quality Indicators 9 and 10Pressure Ulcer Debridement for Systemic InfectionIF a vulnerable elder with a full-thickness pressure ulcer presents with systemic signs and symptoms of infection, such as elevated temperature, leukocytosis, confusion, and agitation, and these signs and symptoms do not have another identified cause, THEN the ulcer should be debrided of necrotic tissue within 12 hours BECAUSE debridement will reduce dead tissue that provides a medium for bacterial invasion and may lead to systemic infection.Pressure Ulcer Culture for Systemic InfectionIF a vulnerable elder with a full-thickness pressure ulcer presents with systemic signs and symptoms of infection, such as elevated temperature, leukocytosis, confusion, and agitation, and these signs and symptoms do not have another identified cause, THEN a tissue biopsy or needle aspiration sample should be obtained and sent for culture and sensitivity testing within 12 hours BECAUSE high bacterial burdens inhibit wound healing and may lead to systemic infection, and needle aspiration or tissue biopsy is the best indicator of bacterial invasion into tissue.Supporting Evidence. Wound infection extends the inflammatory phase of healing, delays collagen synthesis, retards epithelialization, and causes more injury to the tissues because the bacteria produce toxic by-products and compete with fibroblasts and other cells for limited amounts of oxygen and nutrients (50, 51).Signs and symptoms of systemic infection may be due to spread from a full-thickness pressure ulcer. To treat the infection, the source of the infection must be identified; impediments to healing must be removed; and, if possible, the organism causing the infection must be identified. Standard swab cultures do not aid in diagnosis of infection in pressure ulcers because they detect only surface contaminants and not the organism that caused the tissue infection (52). The AHCPR pressure ulcer treatment guidelines recommend wound culture of a tissue biopsy or needle aspiration sample when infection is suspected (25). This procedure may be impractical at some centers, and the NPUAP supports use of a specialized swab technique to culture pressure ulcer wound beds (24, 53). The recommended method of quantitative swab culture involves cleansing the wound with solution that contains no antiseptic. The end of a sterile cotton-tipped applicator is rotated in a 1-cm2 area of the wound for 5 seconds (53, 54) with enough pressure to cause tissue fluid to be absorbed in the cotton tip of the swab. The swab tip is inserted in the tube containing transport media and is sent to the laboratory. Swab culture was not included in the indicator because of the difficulty in distinguishing technique from the medical record.Tissue biopsy is removal of a piece of tissue by using a scalpel or a punch biopsy instrument. The area may be treated with topical anesthetic or injected with local anesthetic. The biopsy is pressure is to the area to and the tissue is sent to the laboratory. aspiration involves of a needle to a with of in the through to the is by the to the The needle is and at for two to The is to the the needle is and and the is sent to the the of systemic infection, the full-thickness ulcer should be treated to decrease the that it is a source of bacterial This is particularly for wounds with that are generally or with necrotic For such ulcers, healing time is because tissue may be Debridement of the with to of or removes dead tissue that provides a medium for bacterial growth and Because systemic infection is debridement of the wound bed should be done within 12 Indicator a vulnerable elder presents with a clean full-thickness or a partial-thickness pressure ulcer, THEN a moist environment should be with topical dressings BECAUSE wounds heal better in a moist Evidence. Several investigators have a moist environment with dry dressings for wound healing. have noted faster healing with moist wound dressings than with wet-to-dry saline gauze dressings (22, The AHCPR guidelines on pressure ulcer treatment which are supported by the American Medical Directors Association (3) and NPUAP also the use of moist dressings over dry an increase in pressure ulcer the of the AHCPR guidelines on pressure ulcers, quality indicators are supported by substantial a literature and with a expert panel 11 valid quality indicators for pressure ulcers were identified. These indicators pressure ulcer care from prevention and assessment to topical Although they are not they provide a baseline for measures that may between quality and Pressure Pressure Ulcers in Prediction and of Health and Health Agency for Health Care Policy and AHCPR Pressure American Medical Directors A study of pressure ulcer prevalence and in care Wound National prevalence pressure ulcer a on Wound The for Quality Wound for 30 October Healthy People of Health and Assessing care of vulnerable methods for developing quality A quantitative analysis of wound characteristics as early predictors of healing in Los University of California, Los Pressure and Wound A for and Braden Bergstrom validity of the Braden Scale for pressure risk in a nursing home Bergstrom Braden pressure ulcer a multisite study of the predictive validity of the Braden Bergstrom Braden study of of pressure ulcers and the relationship between risk characteristics, and prescription of preventive Bergstrom Braden A prospective study of pressure risk among A comparison of patient risk for pressure ulcer development with nursing use of preventive on Pressure Ulcer National Pressure Ulcer Advisory at The role of nutrition in prevention and healing of pressure ulcers. in the of pressure and nutritional Pressure among hospitalized factors for pressure A comparison of and beds or therapy for pressure A pressure healing with van Rijswijk Braden Pressure ulcer patient and wound an AHCPR Wound of National Pressure Ulcer Advisory Wound

Objective To study the effect of negative pressure wound therapy combined with local oxygen therapy on the treatment of pressure ulcers. Methods From January 2015 to December 2016, 60 patients with pressure ulcers over Ⅲ stage admitted in Department of Burns and Plastic Surgery, Air Force General Hospital, People′s Liberation Army, were divided into 3 groups according to the random number table method: conventional dressing change group, negative pressure wound therapy group and negative pressure wound therapy combined with local oxygen therapy group, 20 cases in each group. Conventional dressing change group and negative pressure wound therapy group were respectively given conventional dressing method, negative pressure wound treatment. Negative pressure wound therapy combined with local oxygen therapy group was given negative pressure to attract wounds with local oxygen therapy. Immediately after admission, at the 1st, 2nd, 3rd, 4th, 5th, 6th, 7th and 8th week after treatment, the maximum length, width, depth, exudation, tissue type and wound shrinkage were observed. Date were processed with analysis of variance and LSD test. Results The length, width and depth of pressure ulcers in the negative pressure wound therapy group were significantly decreased as compared to conventional dressing change group, while the decrease in negative pressure wound therapy combined with local oxygen therapy group was more significant, the differences were statistically significant (with P values below 0.05). The length, width and depth in conventional dressing group at the 8th week after treatment were (3.04±0.43), (3.63±0.88), and (1.55±0.77) cm, while in the negative pressure wound therapy group were (2.14±0.71), (2.65±1.27), and (1.05±0.62) cm, and in negative pressure wound therapy combined with local oxygen therapy group, there were (1.17±0.28), (1.39±2.37), and (0.58±0.45) cm. In the negative pressure wound therapy group, the exudation was reduced, the wound granulation tissue was increased, and the wound size was more reduced. All the above effect in the negative pressure wound therapy combined with local oxygen therapy group were obviously superior to negative pressure wound therapy group, the differences were statistically significant (with P values below 0.05). Conclusion Negative pressure wound therapy combined with local oxygen therapy can significantly promote wound healing, reduce exudation and promote the growth of granulation of pressure ulcers, it is better than the only use of negative pressure treatment, which can be applied as a new effective treatment method in the future. Key words: Pressure ulcer; Negative-pressure wound therapy; Oxygen; Wound healing

Pressure ulcers are associated with significant rates of morbidity and mortality, particularly in the geriatric and spinal cord-injured populations. Newer pharmacologically active therapies include the use of topically applied recombinant human platelet-derived growth factor-BB (becaplermin), the active ingredient in REGRANEX) (becaplermin) Gel 0.01%, which has been approved in the United States for treatment of lower extremity diabetic neuropathic ulcers that extend into the subcutaneous tissue or beyond and have an adequate blood supply. In this study, the efficacy of becaplermin gel in the treatment of chronic full thickness pressure ulcers was compared with that of placebo gel. A total of 124 adults (>/= 18 years of age) with pressure ulcers were assigned randomly to receive topical treatment with becaplermin gel 100 microg/g (n = 31) or 300 microg/g (n = 32) once daily alternated with placebo gel every 12 hours, becaplermin gel 100 microg/g twice daily (n = 30), or placebo (sodium carboxymethylcellulose) gel (n = 31) twice daily until complete healing was achieved or for 16 weeks. All treatment groups received a standardized regimen of good wound care throughout the study period. Study endpoints were the incidence of complete healing, the incidence of >/= 90% healing, and the relative ulcer volume at endpoint (endpoint/baseline). Once-daily treatment of chronic pressure ulcers with becaplermin gel 100 microg/g or 300 microg/g significantly increased the incidences of complete and >/= 90% healing and significantly reduced the median relative ulcer volume at endpoint compared with that of placebo gel (p < 0.025 for all comparisons). Becaplermin gel 300 microg/g did not result in a significantly greater incidence of healing than that observed with 100 microg/g. Treatment with becaplermin gel was generally well tolerated and the incidence of adverse events was similar among treatment groups. In conclusion, once-daily application of becaplermin gel is efficacious in the treatment of chronic full thickness pressure ulcers.

ACP Guidelines for Preventing, Treating Pressure Ulcers

Porcine tri-layer wound matrix for the treatment of stage IV pressure ulcers

To describe and provide baseline data from The National Pressure Ulcer Long-Term Care Study (NPULS). Retrospective cohort study of detailed resident characteristics, treatments, and outcomes using convenience sampling. One hundred nine long-term care facilities throughout the United States. Two thousand four hundred twenty adult residents aged 18 and older, with a length of stay of 14 days or longer and who were at risk of developing a pressure ulcer, as defined by a Braden Scale for Predicting Pressure Sore Risk More than 500 characteristics were obtained for each resident over a 12-week period. This paper describes the NPULS database with respect to the resident (sex, age, diagnoses, severity of illness scores, Braden Scale score, activities of daily living, cognitive ability, mobility, bowel or bladder incontinence, laboratory values, nutritional assessment, and pressure ulcer assessment documentation), treatment (nutritional interventions, pressure relieving devices, incontinence interventions, protective devices, turning schedules, and pressure ulcer treatments), and outcome variables (pressure ulcer development and healing, pressure ulcer and systemic infection, changes in nutritional status, and discharge disposition) associated with pressure ulcers. Descriptive statistics and bivariate associations were used for preliminary analyses of resident, treatment, and outcome characteristics. The average age +/- standard deviation was 79.7 +/- 14.2; 70% of the residents were female. Fifty-three percent of residents (n = 1,293) were at risk of developing a pressure ulcer but never developed one during the study (Group 1), 19% developed a new pressure ulcer during the study (n = 457) (Group 2), 22% had an existing pressure ulcer (n = 534) (Group 3), and 6% had an existing pressure ulcer and developed a new ulcer during the study (n = 136) (Group 4). Residents who developed a new pressure ulcer (Group 2) were more likely to be female, older, cognitively impaired, and immobile than residents who had an existing pressure ulcer (Group 3). This baseline study describes the NPULS database with respect to the resident, treatment, and outcome variables associated with pressure ulcers. Future studies will focus on multivariate analyses for risk factor prediction of pressure ulcer development and pressure ulcer healing. Research-based pressure ulcer prevention and treatment protocols can then be developed.

Pressure ulcers, also known as bedsores, pressure sores, or pressure injuries, are localised damage to the skin and underlying soft tissue, usually caused by intense or long-term pressure, shear, or friction. Negative pressure wound therapy (NPWT) has been widely used in the treatment of pressure ulcers, but its effect needs to be further clarified. This is an update of a Cochrane Review first published in 2015. To evaluate the effectiveness of NPWT for treating adult with pressure ulcers in any care setting. On 13 January 2022, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase, and EBSCO CINAHL Plus. We also searched ClinicalTrials.gov and the WHO ICTRP Search Portal for ongoing and unpublished studies and scanned reference lists of relevant included studies as well as reviews, meta-analyses, and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication, or study setting. We included published and unpublished randomised controlled trials (RCTs) comparing the effects of NPWT with alternative treatments or different types of NPWT in the treatment of adults with pressure ulcers (stage II or above). Two review authors independently conducted study selection, data extraction, risk of bias assessment using the Cochrane risk of bias tool, and the certainty of the evidence assessment using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology. Any disagreement was resolved by discussion with a third review author. This review included eight RCTs with a total of 327 randomised participants. Six of the eight included studies were deemed to be at a high risk of bias in one or more risk of bias domains, and evidence for all outcomes of interest was deemed to be of very low certainty. Most studies had small sample sizes (range: 12 to 96, median: 37 participants). Five studies compared NPWT with dressings, but only one study reported usable primary outcome data (complete wound healing and adverse events). This study had only 12 participants and there were very few events; only one participant was healed in the study (risk ratio (RR) 3.00, 95% confidence interval (CI) 0.15 to 61.74, very low-certainly evidence). There was no evidence of a difference in the number of participants with adverse events in the NPWT group and the dressing group, but the evidence for this outcome was also assessed as very low certainty (RR 1.25, 95% CI 0.64 to 2.44, very low-certainty evidence). Changes in ulcer size, pressure ulcer severity, cost, and pressure ulcer scale for healing (PUSH) sores were also reported, but we were unable to draw conclusions due to the low certainly of the evidence. One study compared NPWT with a series of gel treatments, but this study provided no usable data. Another study compared NPWT with 'moist wound healing', which did not report primary outcome data. Changes in ulcer size and cost were reported in this study, but we assessed the evidence as being of very low certainty; One study compared NPWT combined with internet-plus home care with standard care, but no primary outcome data were reported. Changes in ulcer size, pain, and dressing change times were reported, but we also assessed the evidence as being of very low certainty. None of the included studies reported time to complete healing, health-related quality of life, wound infection, or wound recurrence. The efficacy, safety, and acceptability of NPWT in treating pressure ulcers compared to usual care are uncertain due to the lack of key data on complete wound healing, adverse events, time to complete healing, and cost-effectiveness. Compared with usual care, using NPWT may speed up the reduction of pressure ulcer size and severity of pressure ulcer, reduce pain, and dressing change times. Still, trials were small, poorly described, had short follow-up times, and with a high risk of bias; any conclusions drawn from the current evidence should be interpreted with considerable caution. In the future, high-quality research with large sample sizes and low risk of bias is still needed to further verify the efficacy, safety, and cost-effectiveness of NPWT in the treatment of pressure ulcers. Future researchers need to recognise the importance of complete and accurate reporting of clinically important outcomes such as the complete healing rate, healing time, and adverse events.

Review objective The objective of this review is to establish whether using the Braden subscale mobility assessment is comparable to using the full Braden assessment scale. The specific review questions to be addressed are: 1. What preventive pressure ulcer nursing interventions are initiated based on assessment of mobility impairment alone or in comparison with the full Braden risk assessment scale? 2. What is the effect of using mobility assessment alone on incidence of hospital acquired pressure ulcers? Inclusion criteria Types of participants This review will consider studies that include adult patients, 18 years and older, in acute care setting who are at risk of developing pressure ulcers. At risk patients are those identified using Braden risk assessment scale as ‘at risk’, ‘moderate risk’, ‘high risk; and ‘very high risk’ for developing pressure ulcer6, 9 or the sub scale for impaired mobility as ‘completely immobile’, ‘very limited’ and ‘slightly limited’. Studies involving children only and studies conducted in the emergency department only or in the operating room only will be excluded from the review as they are not consistent with the review objective. Types of intervention(s)/Phenomena of interest This review will consider studies that include pressure ulcer risk identified using assessment of the subscale mobility impairment compared with full Braden scale assessment where available. Types of outcomes This review will consider the following primary outcome measures: • Whether patients in either study arm are more or less likely to receive appropriate preventative interventions, including, but not limited to protective mattresses, creams and skin barriers, vitamin supplements, patient positioning etc • Incidence of hospital acquired pressure ulcers Secondary outcome measures: • Reliability of mobility assessment ± Braden assessment • Frequency of assessment

Background: Biological dressings with non-transfusion blood components are among the treatments available for pressure ulcers (PUs). Biological dressings contain active concentrated pro-regenerative molecules that can modify and switch off local inflammatory pathways. This re-establishes the physiological homing, which results in healing. In our study, we used a biological component obtained by ultrafiltration of plasma-platelet concentrate: protein-enriched filtered platelet-rich plasma (PEFPRP) with a higher platelet and higher plasma protein concentration. We tested whether treatment with PEFPRP could improve healing in advanced-stage pressure ulcers with a large surface area. All the patients in this study had a surgical indication but were not able to undergo surgery for various reasons. Materials and methods: Ten patients with severe neurological disability and advanced-stage sacral pressure ulcers were treated with allogenic PEFPRP. The mean lesion surface area at T0 was 13.4cm2 (±9.8 SD). PEFPRP was derived from allogenic plasma-platelet apheresis that had been pre-ultrafiltered with a ProSmart™ filter (Medica, Italy) to obtain a concentration after filtration of the plasma protein (12-16g/dL) and platelet (1-1.2 x 106 microL). Results and Conclusion: All cases showed a reduction in the surface area of the pressure ulcer and in the Pressure Ulcer Scale for Healing (PUSH) score. The mean reduction values at week 6 were as follows: -52% for surface area and -21% for PUSH. Rapid wound healing is fundamental to avoid infections and improve patients' quality of life. This blood component builds new tissue by creating a new extracellular matrix. This, in turn, promotes rapid restoration of the three-dimensional structure of the tissue necessary for healing deeper wounds. PEFPRP shrinks the PU and improves its morphological features (reducing undermining and boosting granulation tissue). PEFPRP also promotes tissue restoration, obtaining an optimal scar. It is a safe and feasible treatment, and these preliminary results support the use of PEFPRP in the treatment of pressure ulcers. PEFPRP dressings could be integrated in the standard treatment of advanced-stage PU.

Pressure ulcers