Pressure Ulcers (Bedsores, Decubitus Ulcers): Strategy of Complex Treatment in a Palliative Care Department, Author's Views From the Standpoint of Clinical Experience

Abstract

Introduction. Weakened, immobile, bedridden patients who occupy a passive position in bed often develop local changes of dystrophic and ulcerative-necrotic changes, decubitus ulcers, which are determined by trophycal disturbances of the skin and underlying tissues. Significant risk factors include diabetes mellitus, conditions after cerebrovascular diseases, Parkinson's disease and other neurological pathologies, and exhaustion in patients with insufficient or inadequate care. Modern scientific research is mainly aimed at developing strategies and methods for the treatment of pressure ulcers that have already formed, which is a local purulent-necrotic process. There is no clear consensus on the criteria for readiness of bedsores (which affects the outcome of surgery) for surgical treatment, which ultimately determines the length of the hospital care of palliative patients.
 Objective. To investigate the possibilities and optimize the complex management (surgical treatment, etc.) of decubitus ulcers (pressure ulcers) especially stage III-IV in some rehabilitation medical centres, in particular in the palliative care department.
 Materials and methods. Some cases of decubitus ulcers (pressure ulcers, especially stage III-IV) from palliative care department are being investigated. The total sample of the retro- and prospective analysis included the results of the complex treatment of 412 patients aged 40-93 years: 174 males and 238 females with soft tissue pressure ulcers.
 Results and discussion. Stage I and II pressure ulcers were treated conservatively. In the presence of purulent complications, complex surgical sanation was performed. Clinical plans and treatment included adequate nutritional support, decompression of the area, and sanation of pressure ulcers with antiseptics, including surgical intervention if necessary, adequate local and systemic infection control, and correction of background comorbidities. Based on author's clinical classification and the DOMINATE strategy, we created a simplified strategy, pathogenetically based, and adapted for the treatment of pressure ulcers in a palliative care department with an adequate sequence of care and complex therapy. Under visual and tactile control, purulent area were diagnosed, opened, and revised intraoperative in stages with precise stepwise necro-, and in 7% of patients – with sequestro necrectomy; the formed cavity was washed with a solution of hydrogen peroxide, chlorhexidine, and aqueous povidone-iodine solution, which also achieved complete evacuation of pus and the necrotic detritus. If necessary, we applied counter-perforations. Some purulent cavities were drained with rubber drains, filled with hydrophilic liniment, and swabs soaked in povidone-iodine. The main wound was filled with sterile gauze swabs with hydrophilic liniment. If it was impossible to simultaneously remove necrotic masses from the standpoint of monitoring the patient's general condition or additional/repeated necrosis formation, we used strategies of complex treatment according to standard clinical protocols, tactics of repeated, programmed resanitations/renecrectomies, and antibacterial therapy. Our proposed clinical classification criteria and adapted NODITE clinical strategy are simple and easy to use. Significant reduction of pain, signs of purulent necrotic inflammation, and effective secondary prevention of complications constitute a set of criteria for effectiveness and economic feasibility, which, in our opinion, determines the possibility of introducing into clinical practice. Using the NODITE strategy, we found complete healing of complicated pressure ulcers within 45-60 days in half of the patients in the main group, while in the control group; this figure was only 35.7%. It has been shown that adequate local restriction and sanation of the problem area and the use of special anti-decubitus mattresses in palliative care departments contribute to the regression of the pathological process, granulation and marginal wound epithelialization.
 Conclusion. The strategy for the prevention, care and treatment of complicated bedsores includes N (Nutrition) – adequate nutritional support; O (Offloading) – offloading, decompression – external pressure reduction on the bedsores area by the use of special care products and orthopedic devices, which contributes to the proliferative phase of the wound process; D (Debridement) – opening, removal of pus and necrosis from the wound with precise step-by-step necro- and (if necessary) sequestro necrectomy, with drainage of purulent cavity; I (Infection) – the most appropriate combination of general antibiotic therapy and topical application of antiseptics and antibiotics; T (Tissue management) – creating an appropriate environment in the wound, care, and stimulation of marginal epithelisation; E (Education) – providing appropriate care, monitoring the dynamics of the pressure ulcer wound process and correcting local venous and/or lymphatic stasis.