Appendix 1 Pressure Ulcer Grading
One of the most widely recognised systems for categorising pressure ulcers is that of the National Pressure Ulcer Advisory Panel . Their international classification recognises four categories or stages of pressure ulcer and two categories of unclassifiable pressure injury, in which wound depth and/or extent, or both, cannot be accurately determined unclassifiable pressure ulcers are generally severe and would be grouped clinically with Stage 3 or Stage 4 ulcers :
The two additional categories of unclassifiable wounds are:
- Unstageable/unclassified Obscured fullthickness skin and tissue loss: Fullthickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar on the heel or ischemic limb should not be softened or removed.
Consulting A Healthcare Provider
If you think you or your loved one has a pressure injury, then you should consult a health care provider right away. If you are unsure about a wound that persists on a pressure point or rubbing area of the body, then you should also consult a provider. While you are caring for your wound at home per your providers instructions and the wound gets worse or persists or if there are signs of infection such as redness, swelling, fever, pain or burning, increased drainage, becomes warm to the touch, then consult a health care provider.
The Available Reconstructive Options Are
Split thickness skin grafting
When the ulcer is superficial and vital tissues such as bone, vessels, nerves or tendons are not exposed, and the ulcer is not copiously discharging, skin grafting is the first option for surgical treatment. The slimy layer over the surface of ulcer is sharply debrided to get a healthy vascular bed for skin grafting.
Variety of local flaps can be used to reconstruct the defect created by excision of pressure ulcers. Local transposition, rotation, limberg flap are the available options .3]. Biceps femoris V-Y advancement for ischial pressure sore and perforator based V-Y advancement is another good options if the anatomy permits .
Sacral pressure sore , debridement and cover by local perforator based V-Y advancement flaps , 1-month post-operative , recurrence on the flap after 11 years due to loss of family support and subsequent improper care. Another patient with the same flap after 16-year of follow-up with a proper weight shifting and care showing stable coverage
Medial planter flap for heel sore: A long-standing deep trophic ulcer of heel . The islanded medial planter flap was transposed to the defect and the resultant donor site was covered by split thickness skin graft . The 1-week and 3-month post-operative pictures showing stable coverage. Patient allowed full weight bearing from 6th week along with silicone footpad protection
Microvascular free flaps
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How The Intervention Might Work
Animal experiments conducted over 40 years ago suggested that acute wounds heal more quickly when their surfaces are kept moist rather than left to dry and scab . A moist environment is thought to provide optimal conditions for the cells involved in the healing process, as well as allowing autolytic debridement , which is thought to be an important part of the healing pathway .
The desire to maintain a moist wound environment is a key driver for the use of wound dressings and related topical agents. Whilst a moist environment at the wound site has been shown to aid the rate of epithelialisation in superficial wounds, excess moisture at the wound site can cause maceration of the surrounding skin , and it has also been suggested that dressings that permit fluid to accumulate might predispose wounds to infection . Wound treatments vary in their level of absorbency, so that a very wet wound can be treated with an absorbent dressing to draw excess moisture away and avoid skin damage, whilst a drier wound can be treated with a more occlusive dressing or a hydrogel to maintain a moist environment.
Some dressings are now also formulated with an ‘active’ ingredient .
What Causes Pressure Ulcers To Develop
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Summary Of Findings For The Main Comparison
NMA evidence for individual network: proportion with complete healing interventions versus saline gauze
1Majority of evidence at high risk of bias imprecision: very wide CI .2Imprecision: very wide CI .3Majority of evidence at high risk of bias imprecision: wide CI and direct evidence on collagenase from three studies, 11 events .4Majority of evidence at high risk of bias : imprecision: wide CI and direct evidence on dextranomer from one study, seven participants and four events .5Majority of evidence at high risk of bias imprecision: wide CI .6Majority of evidence at high risk of bias inconsistency: heterogeneity in direct evidence imprecision: wide CI .7Majority of evidence at high risk of bias inconsistency: significant difference between direct and indirect estimates imprecision: very wide CI .8Imprecision: wide CI .9Majority of evidence at high risk of bias : imprecision: wide CI and direct evidence on tripeptide copper gel from one study, six participants and five events .
In this section, we present the results for the individual NMA. Results for the group network are given in Appendix 5.
Interventions and comparisons
The individual network comprised 21 interventions: 13 eligible dressings six topical agents and two supplementary linking interventions .
Risk of bias for the individual network
We report risk of bias in three ways :
Network metaanalysis results
Ranking of treatments
Rankograms for each intervention individual network
Stages Of Pressure Ulcers
If a loved one has been severely injured or is extremely ill, they may need to spend a significant amount of time in bed. Prolonged immobility, while beneficial to recovery, can become problematic if it places persistent pressure on vulnerable skin. Unless preventive steps are taken, pressure ulcers, also known as decubitus ulcers or bedsores, can develop.
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Pressure Ulcer Treatment Products
There is numerous kind of products on the market to prevent and treat pressure ulcer, but they may not all work perfectly for everybody. The symptom and severity level of the sores determine the right pressure sore treatment product.
There is some manufacturer that offers pressure ulcer and bedsore management which include the following.
Posey manufactures and distributes quality and safe products such as foot elevators, heel pillows, heel guards, elbow protectors, memory foam cushions and many more.
Med-Line produces and distributes more than 350,000 products which include pressure ulcer prevention products and supplies.
The Med-Line innovative products can be seen in hospitals, surgery centers, extended-care facilities, home care dealers, physician offices, retail outlets, and home health agencies.
Their products for pressure ulcer treatment include elbow protectors, heel protectors, convoluted foam boots and many others.
Briggs Health Care
This company serves over 50,000 people in the acute care, physician, senior care, and retail markets. They distribute more than 10,000 products which include products for pressure sores treatment too.
Selection Of Appropriate Wound Dressing For Various Wounds
- 1School of Nursing, Jilin University, Changchun, China
- 2Orthopaedic Medical Center, The Second Hospital of Jilin University, Changchun, China
- 3Department of Plastic and Reconstructive Surgery, The First Hospital of Jilin University, Changchun, China
There are many factors involved in wound healing, and the healing process is not static. The therapeutic effect of modern wound dressings in the clinical management of wounds is documented. However, there are few reports regarding the reasonable selection of dressings for certain types of wounds in the clinic. In this article, we retrospect the history of wound dressing development and the classification of modern wound dressings. In addition, the pros and cons of mainstream modern wound dressings for the healing of different wounds, such as diabetic foot ulcers, pressure ulcers, burns and scalds, and chronic leg ulcers, as well as the physiological mechanisms involved in wound healing are summarized. This article provides a clinical guideline for selecting suitable wound dressings according to the types of wounds.
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Stage 4 Pressure Ulcers
- Helps to prevent biofilm formation
- Reduces healing time
It moistens wound dressings and dissolves encrusted bandages or wound dressings during dressing changes.
Prontosan® Gel X proper wound cleansing is essential. The use of Prontosan® Wound Gel X provides long-lasting cleansing and decontamination of the wound bed between dressing changes.
Prontosan® Debridement Pad has been designed to support the wound bed preparation when used in conjunction with Prontosan® Wound Irrigation Solution.
Prevention Of Pressure Ulcers
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Search Methods For Identification Of Studies
Four existing Cochrane Reviews were relevant to this NMA , and the protocol for this NMA complemented the protocols for these four reviews . We automatically included trials from these reviews in this NMA if they reported complete healing outcomes we planned to use the extracted data from these reviews where possible, supplementing if necessary which was required as some reviews had not been completed.
We conducted searches to identify relevant trials not covered by the four Cochrane Reviews as well as recently published trials. We crosschecked the identified trials against those in the 2014 NICE guideline and the 2013 US Agency for Healthcare Research and Quality guideline on treating pressure ulcers to further locate any additional trials we also checked the references of 24 systematic reviews identified by our search.
We searched the following electronic databases to identify reports of relevant randomised clinical trials:
- the Cochrane Wounds Specialised Register
- the Cochrane Central Register of Controlled Trials
- Ovid MEDILINE
- Ovid MEDLINE
- Ovid Embase
- EBSCO CINAHL Plus .
We also searched the following clinical trials registries:
- WHO International Clinical Trials Registry Platform
- EU Clinical Trials Register .
Searching other resources
How To Prevent Pressure Ulcers
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Sensitivity Analysis By Risk Of Bias
The planned sensitivity analysis for risk of bias was to restrict the network to those studies at low or unclear risk of bias. Only 12 studies with 13 interventions remained and these formed three isolated loops.
Instead we conducted a sensitivity analysis which excluded studies that had high risk of bias for two or more domains we excluded seven studies from the joined network one further study was no longer joined into the network. This left 31 studies with 35 comparisons, including 18 interventions and 1513 participants .
The NMA results for interventions versus saline gauze are shown in Table 23 alongside the original data. There were only minor differences. The mean rank order was similar to the original data and the rankograms similarly indicated much imprecision.
How To Treat Pressure Ulcer
When Pressure ulcers are in the early stages, people may be able to treat them at home. Frequently changing positions can help the ulcers heal and keep new ones from forming.
Pressure ulcers can be prevented by periodically repositioning yourself to avoid stress on the skin. Other strategies include taking good care of the skin, maintaining good nutrition and fluid intake, quitting smoking, managing stress, and exercising daily.
MaxioCel, an advanced wound dressing product, provides faster healing to patients suffering from chronic wounds, such as pressure ulcers, diabetic foot ulcers, venous leg ulcers, cavity wounds, and skin abrasions to name some.
MaxioCel range of advanced chitosan dressings has the potential to address this gap and be a real game-changer. With a range of MaxioCel products, millions of patients who need advanced wound care products are being treated every year. MaxioCel with its 360-degree care combined hemostatic, pain management, and scar improvement properties, fulfills a large gap in the market.
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Sacral Decubitus Ulcers Are A Certain Type Of Wound Located On The Lower Back At The Bottom Of The Spine
How to measure a sacral wound. Clock terms can also be used to describe the location of undermining. Use the body as a clock when documenting the length, width, and depth of a wound using the linear method. The braden risk assessment scale can be utilized to assess a patientÃÂ¢s risk of developing a pressure ulcer.
Get the wound depth using a cotton pledget or applicator dipped in a normal saline solution to measure the deepest part of the wound bed. Look closely at the wound and its edges, and then draw the wounds shape. Measure the wound how to measure wound size consistency is key.
Any adult who scores lower than 18 on the braden scale is high risk. For example, you might use words like jagged, red, puffy, or oozing to describe the wound.step 2, use a ruler to measure the length. Remove the applicator and hold it against the ruler to measure the depth of the wound margin based on.
This is particularly important when The total amount of tissue debrided should be listed separately from the wound measurements The six approaches for measuring wound area were simple ruler method , mathematical models , manual planimetry , digital planimetry , stereophotogrammetry and digital imaging method .
Step 1, draw the shape of the wound and write a brief description. Assessing and measuring wounds you completed a skin assessment and found a wound. In all instances of the linear method, the head is at 12:00 and the feet are at 6:00.
Archives Of Plastic Surgery
Pressure Redistribution Support Surfaces And Therapeutic Linens
Selecting the appropriate support surface is determined by many factors. This is key in preventing and managing pressure injuries/ulcers. You want to remember that your patients size and weight will determine the contact area between them and the surface. For example: You wouldn’t want to use a two-inch seating cushion on a 300lb person. The cushion will not help redistribute pressure.
- Therapeutic linens These FDA-cleared bed linens and textiles are designed to address shear and friction factors.
- Surgical surfaces These are designed for patients undergoing a long surgical procedure, or for high-risk patients used to redistribute pressure during a surgical procedure.
- Powered covers The electric powered cover is placed directly over a standard mattress, thereby promoting microclimate.
- Low air loss Continuous forced air flows through tiny pinholes within the mattress to promote microclimate.
- Alternating pressure Individual cells or air bladders inflate in alternating patterns to shift pressure. The patient will still need to be turned and repositioned on this mattress.
- Air fluidized Circulation of filtered air through silicone-coated ceramic beads creates a fluid or flotation of the patient on the surface.
- Static flotation This non-powered support surface uses one or more of the following componentsair, water, foam, or gelto redistribute pressure from vulnerable areas.
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Appendix 6 Assessment Of Risk Of Bias
1. Was the allocation sequence randomly generated?
Low risk of bias
The investigators describe a random component in the sequence generation process such as: referring to a random number table using a computer randomnumber generator coin tossing shuffling cards or envelopes throwing dice drawing of lots.
High risk of bias
The investigators describe a nonrandom component in the sequence generation process. Usually, the description would involve some systematic, nonrandom approach, for example: sequence generated by odd or even date of birth sequence generated by some rule based on date of admission sequence generated by some rule based on hospital or clinic record number.
Insufficient information about the sequence generation process provided to permit a judgement of low or high risk of bias.
2. Was the treatment allocation adequately concealed?
Low risk of bias
Participants and investigators enrolling participants could not foresee assignment because one of the following, or an equivalent method, was used to conceal allocation: central allocation sequentiallynumbered drug containers of identical appearance sequentiallynumbered, opaque, sealed envelopes.
High risk of bias
3. Blinding was knowledge of the allocated interventions adequately prevented during the study?
Low risk of bias
Any one of the following.
High risk of bias
Any one of the following.
4. Were incomplete outcome data adequately addressed?
Low risk of bias