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PRESSURE ULCER MANAGEMENT

NPWT should be considered first line of defense in case of stage IV pressure ulcers and highly exudating stage III pressure ulcers. Using NPWT on deep pressure ulcers that are not responding to any other treatment can significantly promote wound healing.

https://triagemeditechnoida.blogspot.com/2020/09/wound-care.html

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PRESSURE ULCER MANAGEMENT

Pressure ulcer is the most prevalent health issue all around the world. For every 1,000,000 patients who developed Pressure ulcer 65,000 die from complications which presents a major challenge worldwide. Medical research is constantly striving to identify efficient ways for managing this long prevailing issue and reduce the fatality caused due to mismanagement of the pressure ulcers.

Lets understand a little about what exactly are these pressure ulcers, how are they formed and what are the current methods in practice for management of pressure ulcers.

What are Pressure Ulcers?

Pressure Ulcer commonly known as bed sore is an area on the body where there is damage to the skin & underlying tissue due to prolonged pressure, sheer, friction or a combination of all these.  

Fig1. Causes of  Pressure Ulcer Development

Pressure ulcers are commonly observed in the patients with decreased mobility like patients suffering with paralysis or the elderly. The ulcers can occur whenever the body has been in the same position for long duration causing loss of blood flow and skin thinning to the bony prominence area. Hence to maintain the blood flow pressure off loading is highly essential for immobile patients. Image below depicts the pressure points where the ulcers can surface if the body remains in that position for higher durations.

Fig2. Common Points subjected to pressure ulcer

 Along with the immobility of the patient there are certain other factors that cause the tissue more likely to become ischemic even under the same pressure these factors include presence of comorbities such as diabetes, multiple sclerosis, infection. Presence of any of these comorbities can minimize tissue strength with the ability of nervous system respond & to initiate the healing process of the wound.

Intrinsic contributing factors include:

·         Malnutrition

·         Dehydration

·         Impaired mobility

·         Chronic conditions

·         Impaired sensation

·         Decreased LOC

·         Infection

·         Advance age

·         Steroid use

·         Pressure ulcer present

External contributing factors include:

·         Pressure

·         Friction

·         Moisture

·         Incontinence

·         Shear

Stages of Pressure Ulcer

A pressure ulcer can range from a little discoloration of the skin to deep cavity wounds. According to Sullivan and Schoelles (2013), pressure ulcers occur in four stages. Similar to measurements of burn severity, each stage of pressure ulcer severity indicates a different depth and a new layer of tissue affected.

Fig3. Stages of Pressure Ulcer as per Sullivan and Schoelles

However National Pressure Injury advisory panel provides a slightly advanced classification for the pressure ulcers. These six stages are as follows.

Stage1: Non blanch-able erythma

Stage2: Partial thickness skin loss

Stage 3: Full thickness skin loss

Stage 4: Full thickness tissue loss

Stage 5: Unstageable – Depth unknown

Stage 6: Deep tissue injury Depth unknown

Fig4. Stages of Pressure Ulcer as per NPUAP

Fig5. Brief description for different stages of Pressure Ulcers

Pressure Ulcer Prevention

Pressure injuries can be prevented if acted upon timely; few general methods to be used are as below:

1.      Pressure Distribution- This can be done using pressure re-distribution surface, positioning devices, prophylactic dressings etc.

2.      Positioning devices- Pillows can be used for offloading the pressure points

3.      Avoid Sheer or friction – While repositioning the patient avoid causing friction or sheer to the skin

4.      Micro shifting – Perform Small repositioning of the patient, especially in case of non rotating beds

5.      Prophylactic dressings – Use of silicon based foam dressings can be very effective in preventing the wound from further injury

Wound Assessment

PUSH tool is widely used tool for assessing the pressure ulcers.

Nutritional Evaluation

Despite the consensus that adequate nutrition is important in wound healing, documentation of its effect on ulcer healing is limited; recommendations are based on observational evidence and expert opinion. Nutritional screening is part of the general evaluation of patients with pressure ulcers. In patients who are malnourished, dietary consultation is recommended and a swallowing evaluation should be considered. Intervention should include encouraging adequate dietary intake using the patient's favorite foods, mealtime assistance, and snacks throughout the day. High-calorie foods and supplements should be used to prevent malnutrition. If oral dietary intake is inadequate or impractical, enteral or parenteral feeding should be considered, if compatible with the patient's wishes, to achieve positive nitrogen balance (approximately 30 to 35 calories per kg per day and 1.25 to 1.5 g of protein per kg per day). Protein, vitamin C, and zinc supplements should be considered if intake is insufficient and deficiency is present,

Method for Pressure ulcer wound management

There are various options available for the management of the pressure ulcers. Depending on the wound stage the most suitable option can be selected for administration.

Fig6. Pressure ulcer management algorithm

Significance of Negative Pressure Wound Therapy in management of pressure ulcers

NPWT should be considered first line of defense in case of stage IV pressure ulcers and highly exudating stage III pressure ulcers. Using NPWT on deep pressure ulcers that are not responding to any other treatment can significantly promote wound healing.

Using NPWT has multiple benefits such as  

·         Stimulates growth of new granulation tissue

·         Angiogenesis

·         Reduction of edema

·         Sterile wound healing environment

·         Enhanced wound perfusion

·         Decreased bacterial contamination  

·         Decreased anaerobic activity

·         Reduces frequent dressing

·         Faster wound healing

·         Reduced healing time

·         Easy & early patient mobilization

·         Clean & exudates free wound management

·         Enhances patient’s quality of life

·         Reduced infection risk from patient to attendee & from hospital to patient

Treatment Goals with NPWT

·         Provide a temporary wound cover

·         Manage wound fluid and edema

·         Accelerate patient mobility

·         Improve pain management

·         Prevent wound progression

·         Increase dermal and wound perfusion

·         Stimulate formation of granulation tissue

·         Enhance wound bed epithelialization

·         Improve matrix material availability

·         Reduce bacterial load

·         Provide moist wound environment

·         Influence expression of genes involved in wound healing

However while choosing NPWT as method of treatment always consider the contraindication of NPWT is the presence of necrotic or fibrotic tissue, untreated osteomylytis, absence of appropriate blood supply etc.

NPWT is based on assumption that a uniform negative pressure event three-dimensionally creates tissue deformation and cell stretching, leading to metabolic activity and cell proliferation. The most common dressing material is the polyurethane foam sponge with a wide variation in the coarseness of the mesh. The PU foam sponge maintains suitable moisture, it is generally accepted that moisture balance is essential to all phase of wound healing exposed cells of the wound surface require surface moisture for viability while too little can cause cell death, exercise can cause maceration and damage to would edges and peri-wound skin.

Conclusion

Wound care clinicians have a wide array of treatment options available with which to manage and help heal pressure ulcers. Few of the methods have been discussed above however, the challenge is to determine the most appropriate treatment strategy while considering many factors regarding the wound, the patient, and the cost of care to ensure that assessments, treatment pathways, and product selections are both clinically and economically sound.

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Rosidal K - Short Stretch Bandage| Triage Meditech

Rosidal K Short Stretch Bandage offers powerful compression but is also a short stretch textile-elastic bandage. It is used to provide powerful compression of the limbs in phlebology.

https://www.triagemeditech.com/rosidal-k

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Rosidal Lymph | L&R Global| Triage Meditech

L&R is now offering Rosidal Lymph, a new concept with clear advantages for everyday clinical use. 

https://www.triagemeditech.com/rosidal-lymph

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Rosidal TCS compression system| Triage Meditech

Rosidal TCS combines Rosidal SC, an innovative padding compression bandage with integrated fabric for skin protection and Rosidal CC, a cohesive short stretch compression bandage.

https://www.triagemeditech.com/rosidal-tcs

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Insticare VTG2901 Manufacturer & Supplier | Triage Meditech

Insticare VTG2901 new programmable CCNPWT system delivers controlled negative pressure in the wound site to accelerate healing process.

https://www.triagemeditech.com/vtg-2901-new-advanced-solution

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NEGATIVE PRESSURE WOUND THERAPY WITH IRRIGATION

The use of Negative Pressure Wound Therapy system in Chronic Wounds, Venous Ulcers, Diabetic Ulcers, Traumatic Wounds, Post-Operative and Dehisced Surgical Wounds provides a moist wound environment at the wound site thus:

https://triagemeditechnoida.blogspot.com/2020/09/healthcare.html

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NEGATIVE PRESSURE WOUND THERAPY WITH IRRIGATION

The use of negative pressure wound therapy (NPWT) is well established in the treatment of chronic wounds. NPWT with instillation (NPWTi) combines traditional NPWT with the application of a topical irrigation solution within the wound bed. The addition of instillation feature with NPWT adds several potential benefits in dealing with complex wounds.

NPWT WITH IRRIGATION -MECHANISM OF ACTION

Potential mechanisms of action include the removal of microorganisms from the wound surface, dilution of cytotoxic molecules, up-regulation of angiogenesis path ways, and maintenance of a moist wound environment. As we have extended our use of these devices to more complex wounds, we have taken advantage of and observed potential mechanisms of action, including facilitated removal of microorganisms, dilution of inflammatory and cytotoxic macromolecules, additional wound hydration, and enhanced angiogenesis through an intermittent application of NPWT.

 Fig 2. NPWTi MECHANISM OF ACTION

INDICATIONS

Several different types of wounds can benefit from negative pressure wound therapy such as:

●        Trauma wounds

●        Dehisced wounds

●        Chronic wounds

●        Abdominal compartment syndrome

●        Pre & post-op flaps/grafts

●        Diabetic ulcers

●        Venous ulcers

●        Arterial ulcers

●        Pressure ulcers

●        Burn wounds

●        Wounds with large amounts of drainage

●        Surgical and acute wounds at high risk for infection

 CONTRAINDICATIONS

 CCNPWT is contraindicated for below:

●        Malignancy in wound

●        Necrotic tissue with eschar

●        Untreated osteomyelitis

●        Fistulas to organs or body cavities

●        Do not place NPWT dressing over exposed arteries or veins

  CCNPWT ADVANTAGES

The use of Negative Pressure Wound Therapy system in Chronic Wounds, Venous Ulcers, Diabetic Ulcers, Traumatic Wounds, Post-Operative and Dehisced Surgical Wounds provides a moist wound environment at the wound site thus:

1.       Enhances dermal perfusion, decompresses blood vessels.

2.       Reduces bacterial colonization.

3.       Promotes micro angiogenesis.

4.       Promotes uniform granulation tissue formation.

5.       Enhances blood circulation in pressure ulcers.

6.       Reduces communicable infection rate.

7.       Improves bed hygiene as it is a closed system.

8.       Less pain full than the daily dressing change for the patient.

9.       Early usage of NPWT may save limbs in case of diabetic foot and other chronic wounds.

10.    Requires lesser nursing time as dressing needs to be changed only after 4 – 5 days and saves man hours.

11.    Early usage of NPWT may save limbs in case of diabetic foot and other chronic wounds.

12.    Lesser antibiotic usage enhances patient immunity and also cost to the hospital and to the society.

13.    Enhances faster bed rotation in Govt. Hospitals where queue of the hospital bed is huge as patients can be discharged early.

14.    Reduces overall treatment cost and time for the patient & Govt. as the hospitalization time decreases by 2/3rd with the use of NPWT

15.    Improves quality of life of the patient.

16.    It prevents spread of infection to the patient family/ visitors as well as to the neighbouring patients

With all the above advantages Negative Pressure Wound Therapy system would definitively help the patients & staff of your prestigious institutions.

CONCLUSION

The low-income countries like INDIA are having a number of issues related to public health. The use of NPWT in the Indian studies has not been reported extensively. Only few Indian studies have provided insights into the NPWT use in Indian setting. The use of CCNPWT is definitely having an advantage in countries like India, where the patient load on the health centres is very high and where more than 40% of the population earns less than one US dollar per day and where only a small portion of government budget goes to health there is an urgent need of faster and cheaper wound healing techniques.

The health care information about the newer and cheaper techniques will help a great deal in the exponentially growing population. In such a scenario any wound healing technique that will work faster than the conventional techniques and deliver at par or at times better results is definitely a boon. As discussed above in the document CCNPWT has certain advantages like it is easy to handle, hospital admission is not essential, good patient compliance and satisfaction, require minimal training to maintain vacuum at home, can be applied to multiple cases at the same time and give adequate mobility to the patient.

CCNPWT will also reduce the total time spent in the hospital and this is ideal for already overloaded hospitals. Besides, the number of follow-ups will also be reduced in cases involving CCNPWT. But the situation in the rural areas is graver as NPWT is not available everywhere in the developing countries and the usage of NPWT in the rural areas is very difficult due to difficulties related to terrain, availability of devices, cost issues, etc. Thus we highly recommend the use of CCNPWT for wound management which can be used in the rural areas of developing countries is essential. The data available from scientific literature suggest that Negative Pressure Wound Therapy to be a cost-effective technique, resulting in at par or at times better wound healing.

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INTRODUCTION TO NPWT

The relatively newer technique negative pressure wound therapy (NPWT) is very promising and also useful in the management of difficult to heal wounds.

https://triagemeditechnoida.blogspot.com/2020/09/npwt.html

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Insticare VTG2901 V2 Manufacturer & Supplier | Triage Meditech

Insticare 2901 V2 is an upgraded version of VTG 2901, provided with an additional advantage of irrigation aimed at minimizing bacterial colonization by intermittent cleansing of wound and dressing.

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INTRODUCTION TO NPWT

The management of difficult to heal wounds has always been a cause of concern for the treating clinicians. There has been a tremendous increase in the number of patients presenting with difficult to heal wounds. The conventional techniques have been in use since a long time for the management of these wounds, yet desired results are not achieved always. Thus a newer novel technique which might be useful in the difficult to heal wounds and delivering at par or better results as compared to the conventional techniques is the need of the hour. Despite numerous advances, chronic and other difficult to manage wounds continue to be a challenge for the clinicians. The relatively newer technique negative pressure wound therapy (NPWT) is very promising and also useful in the management of difficult to heal wounds. 

The use of controlled levels of negative pressure application has been shown to accelerate debridement and promote healing in various types of wounds. This optimum level of negative pressure appears to be around -125 mmHg below ambient and there is evidence that this is most effective if applied in a cyclical fashion. Earlier studies used more conventional methods such as a wall suction apparatus or surgical vacuum bottles for creating the negative pressure. However, there were multiple problems present in the use of these conventional methods such as non-regulated pressure, high protein loss, cross contamination from infected patients, also the mobility of the patient was restricted. 

Hence we introduced the commercial system for promoting negative pressure wound therapy also known as vacuum therapy, vacuum sealing or topical negative pressure therapy. This equipment called CCNPWT Wound Management system was designed to overcome the problems associated with conventional methods for the creation of negative pressure. The heart of the system is a microprocessor-controlled vacuum unit that is capable of providing controlled levels of continuous or intermittent sub-atmospheric pressure ranging from 

-20mmHg to -220 mmHg. 

NPWT is an efficacious & cost-effective management approach for almost all wound etiology such as pressure ulcers, trauma wounds, acute & chronic wounds, diabetic foot ulcers, venous leg ulcers, burns, post-surgical wounds, pre & post-op flaps/grafts. 

 MECHANISM OF ACTION

The principle of NPWT involves extending the usually narrowly defined suction effect of drainage across the entire area of the wound cavity or surface using an open-pore filler that has been fitted to the contours of the wound. To prevent air from being sucked in from the external environment, the wound and the filler that rests inside or upon the wound are hermetically sealed with an airtight adhesive polyurethane drape that is permeable to water vapour, transparent, and bacteria proof. A connection pad is then applied over a small hole that has been made in the drape and connected to a vacuum source by means of a tube (Fig 1). 

Fig 1. Mechanism of action of Negative pressure Wound Therapy

 Two main theories prevail regarding the mechanism of action of NPWT used in conjunction with reticulated open cell foam: 

The     first is based on the theory that tissue strain caused by NPWT has a     stimulatory effect on cellular proliferation. 

This     theory is supported by the fact that tissues have been shown to undergo a     5-20% strain when subjected to NPWT. 

This     level of strain is assumed to proactively cause cell division and     angiogenesis. 

The     second theory is focused on the effects of NPWT on the mechanical removal of     extracellular fluid and oedema. 

By actively removing fluid at the wound bed it is felt     that the local micro-circulation is improved and secondary necrosis is     reduced. 

This hypothesis is supported by studies which have shown reduced need for debridement at the time of ‘second look’ for wounds treated with NPWT. It is also supported by in vivo studies using a porcine model which have demonstrated acceleration in capillary formation and increase in luminal area in wounds treated with NPWT

 Fig 2. Dressing application technique

NPWT acts in different ways to promote wound healing. The wound is subject to suction pressure that is propagated through the wound filler to the wound bed. This suction drains exudate from the wound and creates a mechanical force in the wound edges that result in an altered tissue perfusion, angiogenesis and the formation of granulation tissue. Some of the mechanisms of action have been demonstrated experimentally and clinically. 

The effects of NPWT on open wound can be summarised as follows:

Reduction     of the wound area due to negative pressure acting on the foam, pulls     together the edges of the wound (wound retraction)

Stimulation     of granulation tissue formation in an optimally moist wound environment; in     several situations even over brady trophic tissue such as tendons and bone     NPWT was able to stimulate granulation tissue formation

Continuation     of effective mechanical wound cleansing (removal of small tissue debris by     suction)

Effective     biochemical reduction of the fluid concentration of wound     healing-impairing proteases (such as elastase)—in the first days

Reliable,     continuous removal of wound exudate (and, consequently, fewer dressing     changes) within a closed system

Pressure-related     reduction of interstitial oedema with consecutive improvement of     microcirculation, stimulation of blood flow and oxygenation

Hygienic     wound closure—bacteria proof wound dressing for sealing the wound so no     external bacteria can enter the wound and the patient’s own wound bacteria     are not spread.

This     is particularly important in the event of contamination with problematic     bacteria, as in patients with meticillin-resistant Staphylococcus     aureus (MRSA)-infected     wounds. Thus, it

also     reduces the risk of cross-infections and development of resistance within     the hospital

Transparent     dressing permits continuous clinical monitoring of the surrounding skin     through the film with which the wound has been sealed

Odourless     and hygienic dressing technique; constant seeping through the dressing     onto the patient’s clothing and bedding can be avoided, reducing demands     on the nursing staff

Reduction in the number of     required dressing changes (only necessary every two to three days), which     reduces nursing time requirements, particularly in patients with exudating     wounds.

Patient comfort

• Easy and early patient mobilisation

• Visually appealing dressing method due to clean, exudate-free dressing conditions even during mobilisation.

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Insticare VTG2901 V2 Manufacturer & Supplier | Triage Meditech

Insticare 2901 V2 is an upgraded version of VTG 2901, provided with an additional advantage of irrigation aimed at minimizing bacterial colonization by intermittent cleansing of wound and dressing.

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Insticare VTG3900 Manufacturer & Supplier | Triage Meditech

Insticare possesses the additional advantage of irrigation aimed at minimizing bacterial colonization by intermittent cleansing of wound and dressing.

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Insticare VTG3900 Manufacturer & Supplier | Triage Meditech

Insticare possesses the additional advantage of irrigation aimed at minimizing bacterial colonization by intermittent cleansing of wound and dressing.

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Vacuport, VTG007 Manufacturer & Supplier | Triage Meditech

VACUPORT is a portable NPWT device especially curated to address the complications of skin graft uptake & surgical wound dehiscence.

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Incicare Hydrophilic NPWT dressing| Triage Meditech

Incicare hydrophilic NPWT dressing is an all-in-one dressing that viably assimilates and holds the patient’s exudates away from the wound surface.

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NPWT Dressings & Accessories | Triage Meditech

Negative pressure wound therapy (NPWT) dressings are for use as an interface between NPWT devices and patient wound beds.