Fast Fact and Concept #041: Pressure Ulcer Management II: Debridement and Dressings

2nd Edition

Author(s): Charles von Gunten, MD and Frank Ferris, MD

The first step in deciding how to manage 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 DuoDerm), 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 DuoDerm 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 if 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. Betadine) 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 (LYOfoam, Allevyn, Nu-Derm, Flexzan). Most absorptive. Used under a covering secondary dressing.
2. Alginates (Kaltostat, 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, Elasto-Gel, ClearSite, Aquasorb). Used for wounds with larger volumes of exudate. Require a secondary dressing to secure.
4. Hydrocolloid wafers (DuoDerm, Comfeel, Tegasorb, 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 absorbent dressing in place..
6. Cotton Gauze. Used to cover the primary dressing. Rarelythe appropriate dressing for a significant skin ulcer. Note: Saline wet-to-dry dressings are only useful for mechanical debridement.

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 Supp. Oncology Updates 2000;3(6):1-11.

Fast Facts were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007.  For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu

Copyright/Referencing Information : Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Fast Facts and Concepts #4. 1von Gunten C and Ferris F. Pressure ulcers: Debridement and dressings, August 2005, 2 nd Edition. End-of-Life / Palliative 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; 2nd Edition, August 2005.

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Non pain symptoms & syndromes