今日の臨床サポート

褥瘡

著者: 門野岳史 聖マリアンナ医科大学 皮膚科

監修: 戸倉新樹 掛川市・袋井市病院企業団立 中東遠総合医療センター 参与/浜松医科大学 名誉教授

著者校正/監修レビュー済:2022/04/27
参考ガイドライン:
  1. 日本褥瘡学会:褥瘡予防・管理ガイドライン(第5版)(2021年)
患者向け説明資料

概要・推奨   

  1. リスクアセスメントスケールを用い褥瘡の危険因子を評価することが推奨される(推奨度2)
  1. 栄養について栄養サポートチーム(NST)に相談することは、褥瘡の予防、ケアに役立つため、強く推奨される(推奨度1)
  1. 体位変換や体圧分散機器を用いることは褥瘡の予防とケアに役立つため、強く推奨される(推奨度1)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
門野岳史 : 奨学(奨励)寄付など(マルホ株式会社)[2022年]
監修:戸倉新樹 : 講演料(マルホ,サノフィ,協和キリン),原稿料(医学書院)[2022年]

改訂のポイント:
  1. 定期レビューを行い、DESIGN-Rの変更および改定となった褥瘡予防・管理ガイドライン(第5版)について記した。

病態・疫学・診察

疾患情報(疫学・病態)  
まとめ:
  1. 褥瘡は、多くの場合は寝たきり状態が原因となって生じる皮膚局所の阻血性壊死である。一定の場所に、一定時間以上の圧迫とともに、摩擦・ずれ、湿潤などの外的要因が加わることで生じる。
  1. 手術室などの特殊な環境下での発症を除くと、褥瘡の多くは詳細な問診、視診、触診によって診断可能である。
  1. 褥瘡の発症・治癒を左右するのは直接的な皮膚局所要因のみでなく、多彩な全身的あるいは社会的二次要因にも影響される。
 
褥瘡の直接原因とそれを取り巻く二次原因

創傷治癒は最終的には肉芽形成と上皮化により完了するが、肉芽形成が起こるためにはそれを阻害する直接原因の皮膚局所の圧迫のみならず、それ以外の多彩な二次的要因、例えば、加齢による皮膚の変化、摩擦やずれ、失禁や湿潤などの局所的要因、低栄養、やせ、加齢や基礎疾患などの全身的要因、さらには、介護のマンパワー不足や経済力不足などの社会的要因も除去する必要がある。

 
医療機器による圧迫創傷:
  1. 最近では、褥瘡に代わり医原性褥瘡、医療機器関連褥瘡、医療機器関連圧迫創などと呼ばれた‘医療機器による圧迫創傷’が注目を集めるようになった。そこで、日本褥瘡学会では、医療関連機器圧迫創傷(medical device related pressure ulcer)を、「医療関連機器による圧迫で生じる皮膚ないし下床の組織損傷であり、厳密には従来の褥瘡すなわち自重関連圧迫創傷(self load related pressure ulcer)と区別されるが、共に圧迫創傷であり広い意味では褥瘡の範疇に属する。なお、尿道、消化管、気管等の粘膜に発生する創傷は含めない」と定義し、上記ガイドラインとは別に、2016年に「ベストプラクティス医療関連機器圧迫創傷の予防と治療」を公表した。
 
医療用弾力ストッキングによる圧迫創傷

 
NPPVフェースマスクによる圧迫創傷

 
酸素チューブによる圧迫創傷

 
A-lineの三方活栓による圧迫創傷

 
  1. 医療機器は薬事法で定義されている(人もしくは動物の疾病の診断、治療もしくは予防に使用されること、または人もしくは動物の身体の構造もしくは機能に影響を及ぼすことが目的とされている機械器具などにあって、法令で定めるものをいう)ので、たとえば手作りの抑制帯などによって生じたものも含まれるよう医療関連機器としている。
病歴・診察のポイント  
  1. 褥瘡の多くは、寝たきり状態の患者(特に老人)の仙骨部など荷重部に発症する。

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文献 

Pedro L Pancorbo-Hidalgo, Francisco Pedro Garcia-Fernandez, Isabel Ma Lopez-Medina, Carmen Alvarez-Nieto
Risk assessment scales for pressure ulcer prevention: a systematic review.
J Adv Nurs. 2006 Apr;54(1):94-110. doi: 10.1111/j.1365-2648.2006.03794.x.
Abstract/Text AIM: This paper reports a systematic review conducted to determine the effectiveness of the use of risk assessment scales for pressure ulcer prevention in clinical practice, degree of validation of risk assessment scales, and effectiveness of risk assessment scales as indicators of risk of developing a pressure ulcer.
BACKGROUND: Pressure ulcers are an important health problem. The best strategy to avoid them is prevention. There are several risk assessment scales for pressure ulcer prevention which complement nurses' clinical judgement. However, some of these have not undergone proper validation.
METHOD: A systematic bibliographical review was conducted, based on a search of 14 databases in four languages using the keywords pressure ulcer or pressure sore or decubitus ulcer and risk assessment. Reports of clinical trials or prospective studies of validation were included in the review.
FINDINGS: Thirty-three studies were included in the review, three on clinical effectiveness and the rest on scale validation. There is no decrease in pressure ulcer incidence was found which might be attributed to use of an assessment scale. However, the use of scales increases the intensity and effectiveness of prevention interventions. The Braden Scale shows optimal validation and the best sensitivity/specificity balance (57.1%/67.5%, respectively); its score is a good pressure ulcer risk predictor (odds ratio = 4.08, CI 95% = 2.56-6.48). The Norton Scale has reasonable scores for sensitivity (46.8%), specificity (61.8%) and risk prediction (OR = 2.16, CI 95% = 1.03-4.54). The Waterlow Scale offers a high sensitivity score (82.4%), but low specificity (27.4%); with a good risk prediction score (OR = 2.05, CI 95% = 1.11-3.76). Nurses' clinical judgement (only considered in three studies) gives moderate scores for sensitivity (50.6%) and specificity (60.1%), but is not a good pressure ulcer risk predictor (OR = 1.69, CI 95% = 0.76-3.75).
CONCLUSION: There is no evidence that the use of risk assessment scales decreases pressure ulcer incidence. The Braden Scale offers the best balance between sensitivity and specificity and the best risk estimate. Both the Braden and Norton Scales are more accurate than nurses' clinical judgement in predicting pressure ulcer risk.

PMID 16553695
Enid Kwong, Samantha Pang, Thomas Wong, Jacqueline Ho, Xue Shao-ling, Tao Li-jun
Predicting pressure ulcer risk with the modified Braden, Braden, and Norton scales in acute care hospitals in Mainland China.
Appl Nurs Res. 2005 May;18(2):122-8. doi: 10.1016/j.apnr.2005.01.001.
Abstract/Text The aim of this study was to develop a modified Braden scale, to evaluate its predictive validity, and to identify a more valid pressure ulcer risk calculator for application in acute care hospitals in Mainland China among the modified Braden, Braden, and Norton scales. The initial modified Braden scale, with the addition of skin type and body build for height, was proposed in this study. Four hundred twenty-nine subjects who were admitted to two acute care hospitals in Mainland China within 24 hr and free of pressure ulcers upon admission were assessed with the initial modified Braden, Braden, and Norton scales by three nurse assessors. This was followed by a daily skin assessment to note any pressure ulcer by a nurse assessor. Nine subjects had pressure ulcers detected at Stages I (89%) and II (11%) after an average stay of 11 days. The descriptive analysis of each subscale scoring item in the initial modified Braden scale indicated that skin type and body build for height were the most distinct predictive factors whereas nutrition was the least distinct factor for predicting pressure ulcer development. Based on these findings, the modified Braden scale was further developed with the addition of skin type and body build for height and by exclusion of nutrition. The predictive validity test reported that the modified Braden scale demonstrated a better balance of sensitivity (89%) and specificity (75%) at a cutoff score of 16, with a higher positive predictive value (7%), than the Braden and Norton scales. This finding revealed that for this sample, the modified Braden scale is more effective in pressure ulcer risk prediction than the other two scales. Because the modified Braden scale is not 100% sensitive and specific, to increase clinical efficacy in the prevention of pressure ulcer, it is recommended that it be adopted combined with nursing judgment to predict pressure ulcer development in acute care settings in Mainland China.

PMID 15991112
Zena E H Moore, Seamus Cowman
Risk assessment tools for the prevention of pressure ulcers.
Cochrane Database Syst Rev. 2008 Jul 16;(3):CD006471. doi: 10.1002/14651858.CD006471.pub2. Epub 2008 Jul 16.
Abstract/Text BACKGROUND: Pressure ulcer risk assessment is a component of the assessment process used to identify individuals at risk of developing a pressure ulcer. Use of a risk assessment tool is recommended by many international pressure ulcer prevention guidelines however it is not known whether using a risk assessment tool makes a difference to patient outcomes. A review was conducted to clarify the role of pressure ulcer risk assessment in clinical practice.
OBJECTIVES: The objective of this review was to determine whether using structured, systematic pressure ulcer risk assessment tools, in any health care setting, reduces the incidence of pressure ulcers.
SEARCH STRATEGY: The following databases were searched: MEDLINE (January 1966 to April Week 3, 2008); EMBASE (1974 to Week 17, 2008); CINAHL (1982 to April Week 4, 2008); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, issue 2, 2008); The Wounds Group Specialised Register (searched 29/4/2008). There were no restrictions on articles on the basis of language or date of publication.
SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing the use of structured, systematic, pressure ulcer risk assessment tools with no structured pressure ulcer risk assessment, or with unaided clinical judgement, or RCTs comparing the use of different structured pressure ulcer risk assessment tools were considered for this review.
DATA COLLECTION AND ANALYSIS: Titles and, where available, abstracts of the studies identified by the search strategy were assessed by two authors independently for their eligibility. Full versions of potentially relevant studies were obtained and screened against the inclusion criteria by two authors independently.
MAIN RESULTS: No studies were identified that met the inclusion criteria.
AUTHORS' CONCLUSIONS: Despite the widespread use of risk assessment tools for the assessment of individuals' risk of developing pressure ulcers, no randomised trials exist that compare them with unaided clinical judgement or no risk assessment in terms of rates of pressure ulceration. Therefore, we cannot conclude whether the use of structured, systematic pressure ulcer risk assessment tools, in any health care setting, reduces the incidence of pressure ulcers. The effect of structured risk assessment tools on pressure ulcer incidence needs to be evaluated.

PMID 18646157
Rebecca J Stratton, Anna-Christina Ek, Meike Engfer, Zena Moore, Paul Rigby, Robert Wolfe, Marinos Elia
Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis.
Ageing Res Rev. 2005 Aug;4(3):422-50. doi: 10.1016/j.arr.2005.03.005.
Abstract/Text BACKGROUND: There have been few systematic reviews and no meta-analyses of the clinical benefits of nutritional support in patients with, or at risk of developing, pressure ulcers. Therefore, this systematic review and meta-analysis was undertaken to address the impact of enteral nutritional support on pressure ulcer incidence and healing and a range of other clinically relevant outcome measures in this group.
METHODS: Fifteen studies (including eight randomised controlled trials (RCTs)) of oral nutritional supplements (ONS) or enteral tube feeding (ETF), identified using electronic databases (including Pub Med and Cochrane) and bibliography searches, were included in the systematic review. Outcomes including pressure ulcer incidence, pressure ulcer healing, quality of life, complications, mortality, anthropometry and dietary intake were recorded, with the aim of comparing nutritional support versus routine care (e.g. usual diet and pressure ulcer care) and nutritional formulas of different composition. Of these 15 studies, 5 RCTs comparing ONS (4 RCTs) and ETF (1 RCT) with routine care could be included in a meta-analysis of pressure ulcer incidence.
RESULTS: Meta-analysis showed that ONS (250-500 kcal, 2-26 weeks) were associated with a significantly lower incidence of pressure ulcer development in at-risk patients compared to routine care (odds ratio 0.75, 95% CI 0.62-0.89, 4 RCTs, n=1224, elderly, post-surgical, chronically hospitalised patients). Similar results were obtained when a combined meta-analysis of ONS (4 RCT) and ETF (1 RCT) trials was performed (OR 0.74, 95% CI 0.62-0.88, 5 RCTs, n=1325). Individual studies showed a trend towards improved healing of existing pressure ulcers with disease-specific (including high protein) versus standard formulas, although robust RCTs are required to confirm this. Although some studies indicate that total nutritional intake is improved, data on other outcome measures (quality of life) are lacking.
CONCLUSIONS: This systematic review shows enteral nutritional support, particularly high protein ONS, can significantly reduce the risk of developing pressure ulcers (by 25%). Although studies suggest ONS and ETF may improve healing of PU, further research to confirm this trend is required.

PMID 16081325
G Langer, G Schloemer, A Knerr, O Kuss, J Behrens
Nutritional interventions for preventing and treating pressure ulcers.
Cochrane Database Syst Rev. 2003;(4):CD003216. doi: 10.1002/14651858.CD003216.
Abstract/Text BACKGROUND: Pressure ulcers affect 10% of people in hospitals and older people are at highest risk. The correlation between nutritional intake and the development of pressure ulcers is suggested by several studies, but the results are inconsistent.
OBJECTIVES: To evaluate the effectiveness of enteral and parenteral nutrition on the prevention and treatment of pressure ulcers.
SEARCH STRATEGY: The Cochrane Wounds Group Specialised Trials Register and the Cochrane Central register of Controlled Trials were searched in September 2002. An additional search of PubMed and Cinahl and hand search of conference proceedings and journals was performed, bibliographies of relevant articles were examined and experts in the field as well as manufacturers were contacted in order to find additional literature that may be relevant.
SELECTION CRITERIA: Randomised controlled trials evaluating the effectiveness of enteral or parenteral nutrition on the prevention and treatment of pressure ulcers by measuring the incidence of new ulcers, ulcer healing or changes in pressure ulcer severity. There were no restrictions on patients, setting, date, publication status or language.
DATA COLLECTION AND ANALYSIS: Abstracts were independently inspected and full articles were obtained of potentially relevant studies. In case of disagreement advice was sought from a third person (AK). Data extraction and assessment of quality were undertaken by the three reviewers independently.
MAIN RESULTS: Only 8 randomised controlled trials out of 16 potentially relevant articles were included. However, most of the 8 trials included are small and of poor methodological quality.
PREVENTION: Four studies compared a combination of nutritional supplements, consisting of a minimum of energy and protein in different dosages, for the prevention of pressure ulcers. The largest study found that nutritional supplements reduced the number of new pressure ulcers (Bourdel-M 2000). The three smaller studies lacked power.
TREATMENT: Four studies evaluated the effects of nutritional supplements for the treatment of existing pressure ulcers: one trial examined mixed nutritional supplements, one trial examined zinc, another the effect of proteins, and two studies compared ascorbic acid. The trials included are heterogeneous with regard to participants, interventions and outcomes; therefore it was considered inappropriate to perform a meta-analysis.
REVIEWER'S CONCLUSIONS: It was not possible to draw any firm conclusions on the effect of enteral and parenteral nutrition on the prevention and treatment of pressure ulcers. Further trials of high methodological quality are necessary.

PMID 14583961
Elizabeth McInnes, Sally Em Bell-Syer, Jo C Dumville, Rosa Legood, Nicky A Cullum
Support surfaces for pressure ulcer prevention.
Cochrane Database Syst Rev. 2008 Oct 8;(4):CD001735. doi: 10.1002/14651858.CD001735.pub3. Epub 2008 Oct 8.
Abstract/Text BACKGROUND: Pressure ulcers (also known as bedsores, pressure sores, decubitus ulcers) are areas of localised damage to the skin and underlying tissue due to pressure, shear or friction. They are common in the elderly and immobile and costly in financial and human terms. Pressure-relieving beds, mattresses and seat cushions are widely used as aids to prevention in both institutional and non-institutional settings.
OBJECTIVES: This systematic review seeks to answer the following questions:(1) to what extent do pressure-relieving cushions, beds, mattress overlays and mattress replacements reduce the incidence of pressure ulcers compared with standard support surfaces?(2) how effective are different pressure-relieving surfaces in preventing pressure ulcers, compared to one another?
SEARCH STRATEGY: For this second update the Cochrane Wounds Group Specialised Register was searched (28/2/08), The Cochrane Central Register of Controlled Trials (CENTRAL)(2008 Issue 1), Ovid MEDLINE (1950 to February Week 3 2008), Ovid EMBASE (1980 to 2008 Week 08) and Ovid CINAHL (1982 to February Week 3 2008). The reference sections of included studies were searched for further trials.
SELECTION CRITERIA: Randomised controlled trials (RCTs), published or unpublished, which assessed the effectiveness of beds, mattresses, mattress overlays, and seating cushions for the prevention of pressure ulcers, in any patient group, in any setting. Study selection was undertaken by at least two authors independently with a third author resolving uncertainty. RCTs were eligible for inclusion if they reported an objective, clinical outcome measure such as incidence and severity of new of pressure ulcers developed. Studies which only reported proxy outcome measures such as interface pressure were excluded.
DATA COLLECTION AND ANALYSIS: Trial data were extracted by one researcher and checked by a second. The results from each study are presented as relative risk for dichotomous variables. Where deemed appropriate, similar studies were pooled in a meta analysis.
MAIN RESULTS: For this second update 11 trials met the inclusion criteria bringing the total number of RCTs included in the review to 52.Foam alternatives to the standard hospital foam mattress can reduce the incidence of pressure ulcers in people at risk. The relative merits of alternating and constant low pressure devices are unclear. There is one high quality trial comparing the different alternating pressure devices for pressure ulcer prevention which suggests that alternating pressure mattresses may be more cost effective than alternating pressure overlays.Pressure-relieving overlays on the operating table have been shown to reduce postoperative pressure ulcer incidence, although two studies indicated that foam overlays resulted in adverse skin changes. Two trials indicated that Australian standard medical sheepskins prevented pressure ulcers. There is insufficient evidence to draw conclusions on the value of seat cushions, limb protectors and various constant low pressure devices as pressure ulcer prevention strategies.A study of Accident & Emergency trolley overlays did not identify a reduction in pressure ulcer incidence. There are tentative indications that foot waffle heel elevators, a particular low air loss hydrotherapy mattress and two types of operating theatre overlays are harmful.
AUTHORS' CONCLUSIONS: In people at high risk of pressure ulcer development higher specification foam mattresses rather than standard hospital foam mattresses should be used. The relative merits of higher-tech constant low pressure and alternating pressure for prevention are unclear but alternating pressure mattresses may be more cost effective than alternating pressure overlays. Medical grade sheepskins are associated with a decrease in pressure ulcer development. Organisations might consider the use of some forms of pressure relief for high risk patients in the operating theatre. Seat cushions and overlays designed for use in Accident & Emergency settings have not been adequately evaluated.

PMID 18843621
N Cullum, E McInnes, S E M Bell-Syer, R Legood
Support surfaces for pressure ulcer prevention.
Cochrane Database Syst Rev. 2004;(3):CD001735. doi: 10.1002/14651858.CD001735.pub2.
Abstract/Text BACKGROUND: Pressure ulcers (also known as bedsores, pressure sores, decubitus ulcers) are areas of localised damage to the skin and underlying tissue due to pressure, shear or friction. They are common in the elderly and immobile and costly in financial and human terms. Pressure-relieving beds, mattresses and seat cushions are widely used as aids to prevention in both institutional and non-institutional settings.
OBJECTIVES: This systematic review seeks to answer the following questions: to what extent do pressure-relieving cushions, beds, mattress overlays and mattress replacements reduce the incidence of pressure ulcers compared with standard support surfaces? how effective are different pressure-relieving surfaces in preventing pressure ulcers, compared to one another?
SEARCH STRATEGY: The Specialised Trials Register of the Cochrane Wounds Group (compiled from regular searches of many electronic databases including MEDLINE, CINAHL and EMBASE plus handsearching of specialist journals and conference proceedings) was searched up to January 2004, Issue 3, 2004 of the Cochrane Central Register of Controlled Trials was also searched. The reference sections of included studies were searched for further trials.
SELECTION CRITERIA: Randomised controlled trials (RCTs), published or unpublished, which assessed the effectiveness of beds, mattresses, mattress overlays, and seating cushions for the prevention of pressure ulcers, in any patient group, in any setting. RCTs were eligible for inclusion if they reported an objective, clinical outcome measure such as incidence and severity of new of pressure ulcers developed. Studies which only reported proxy outcome measures such as interface pressure were excluded.
DATA COLLECTION AND ANALYSIS: Trial data were extracted by one researcher and checked by a second. The results from each study are presented as relative risk for dichotomous variables. Where deemed appropriate, similar studies were pooled in a meta analysis.
MAIN RESULTS: 41 RCTs were included in the review. Foam alternatives to the standard hospital foam mattress can reduce the incidence of pressure ulcers in people at risk. The relative merits of alternating and constant low pressure devices, and of the different alternating pressure devices for pressure ulcer prevention are unclear.Pressure-relieving overlays on the operating table have been shown to reduce postoperative pressure ulcer incidence, although one study indicated that an overlay resulted in adverse skin changes. One trial indicated that Australian standard medical sheepskins prevented pressure ulcers. There is insufficient evidence to draw conclusions on the value of seat cushions, limb protectors and various constant low pressure devices as pressure ulcer prevention strategies.A study of Accident & Emergency trolley overlays did not identify a reduction in pressure ulcer incidence. There are tentative indications that foot waffle heel elevators, a particular low air loss hydrotherapy mattress and an operating theatre overlay are harmful.
REVIEWERS' CONCLUSIONS: In people at high risk of pressure ulcer development, consideration should be given to the use of higher specification foam mattresses rather than standard hospital foam mattresses. The relative merits of higher-tech constant low pressure and alternating pressure for prevention are unclear. Organisations might consider the use of pressure relief for high risk patients in the operating theatre, as this is associated with a reduction in post-operative incidence of pressure ulcers. Seat cushions and overlays designed for use in Accident & Emergency settings have not been adequately evaluated.

PMID 15266452
JoAnne Whitney, Linda Phillips, Rummana Aslam, Adrian Barbul, Finn Gottrup, Lisa Gould, Martin C Robson, George Rodeheaver, David Thomas, Nancy Stotts
Guidelines for the treatment of pressure ulcers.
Wound Repair Regen. 2006 Nov-Dec;14(6):663-79. doi: 10.1111/j.1524-475X.2006.00175.x.
Abstract/Text
PMID 17199832
Madhuri Reddy, Sudeep S Gill, Paula A Rochon
Preventing pressure ulcers: a systematic review.
JAMA. 2006 Aug 23;296(8):974-84. doi: 10.1001/jama.296.8.974.
Abstract/Text CONTEXT: Pressure ulcers are common in a variety of patient settings and are associated with adverse health outcomes and high treatment costs.
OBJECTIVE: To systematically review the evidence examining interventions to prevent pressure ulcers.
DATA SOURCES AND STUDY SELECTION: MEDLINE, EMBASE, and CINAHL (from inception through June 2006) and Cochrane databases (through issue 1, 2006) were searched to identify relevant randomized controlled trials (RCTs). UMI Proquest Digital Dissertations, ISI Web of Science, and Cambridge Scientific Abstracts were also searched. All searches used the terms pressure ulcer, pressure sore, decubitus, bedsore, prevention, prophylactic, reduction, randomized, and clinical trials. Bibliographies of identified articles were further reviewed.
DATA SYNTHESIS: Fifty-nine RCTs were selected. Interventions assessed in these studies were grouped into 3 categories, ie, those addressing impairments in mobility, nutrition, or skin health. Methodological quality for the RCTs was variable and generally suboptimal. Effective strategies that addressed impaired mobility included the use of support surfaces, mattress overlays on operating tables, and specialized foam and specialized sheepskin overlays. While repositioning is a mainstay in most pressure ulcer prevention protocols, there is insufficient evidence to recommend specific turning regimens for patients with impaired mobility. In patients with nutritional impairments, dietary supplements may be beneficial. The incremental benefit of specific topical agents over simple moisturizers for patients with impaired skin health is unclear.
CONCLUSIONS: Given current evidence, using support surfaces, repositioning the patient, optimizing nutritional status, and moisturizing sacral skin are appropriate strategies to prevent pressure ulcers. Although a number of RCTs have evaluated preventive strategies for pressure ulcers, many of them had important methodological limitations. There is a need for well-designed RCTs that follow standard criteria for reporting nonpharmacological interventions and that provide data on cost-effectiveness for these interventions.

PMID 16926357
Tom Defloor, Dirk De Bacquer, Maria H F Grypdonck
The effect of various combinations of turning and pressure reducing devices on the incidence of pressure ulcers.
Int J Nurs Stud. 2005 Jan;42(1):37-46. doi: 10.1016/j.ijnurstu.2004.05.013.
Abstract/Text BACKGROUND: Turning is considered to be an effective way of preventing pressure ulcers, however almost no research has been undertaken on this method.
AIM: The aim of the study was to investigate the effect of four different preventative regimes involving either frequent turning (2, 3 hourly) or the use of a pressure-reducing mattress in combination with less frequent turning (4, 6 hourly).
SUBJECTS: 838 geriatric nursing home patients participated in the study.
METHODS: During 28 days, four different turning schemes were used: turning every 2 h on a standard institutional (SI) mattress (n = 65), turning every 3 h on a SI mattress (n = 65), turning every 4 h on a viscoelastic foam (VE) mattress (n = 67), and turning every 6h on a VE mattress (n = 65). The remaining patients (n = 576) received standard preventive care.
MAIN RESULTS: The incidence of non-blanchable erythema (34.8-38.1%) was not different between the groups. The incidence of grade II and higher pressure ulcers in the 4h interval group was 3.0%, compared with incidence figures in the other groups varying between 14.3% and 24.1%.
CONCLUSIONS: Turning every 4 h on a VE mattress resulted in a significant reduction in the number of pressure ulcer lesions and makes turning a feasible preventive method in terms of effort and cost.

PMID 15582638
Katrien Vanderwee, Maria H F Grypdonck, Tom Defloor
Effectiveness of an alternating pressure air mattress for the prevention of pressure ulcers.
Age Ageing. 2005 May;34(3):261-7. doi: 10.1093/ageing/afi057. Epub 2005 Mar 11.
Abstract/Text BACKGROUND: studies of the effectiveness of alternating pressure air mattresses (APAMs) for the prevention of pressure ulcers are scarce and in conflict.
OBJECTIVE: evaluating whether an APAM is more or equally effective as the standard prevention.
DESIGN: randomised controlled trial. Setting and subjects: patients admitted to 19 surgical, internal, or geriatric wards in seven Belgian hospitals were included if they were in need of prevention of pressure ulcers. To define this need, two methods were used randomly: the Braden Scale or the presence of non-blanchable erythema (NBE).
METHODS: 447 patients were randomised into either an experimental or a control group. In the experimental group, 222 patients were lying on an APAM (Alpha-X-Cell, Huntleigh Healthcare, UK). In the control group, 225 patients were lying on a visco-elastic foam mattress (Tempur, Tempur-World Inc., USA) in combination with turning every 4 hours. Both groups had identical sitting protocols.
RESULTS: there was no significant difference in incidence of pressure ulcers (grade 2-4) between the experimental (15.6%) and control group (15.3%) (P = 1). There were significantly more heel pressure ulcers in the control group (P = 0.006). There was an interaction effect between the risk assessment method and preventive measures for the development of all pressure ulcers and sacral pressure ulcers.
CONCLUSION: fewer patients developed heel pressure ulcers on an APAM. Patients identified as being in need of prevention based on the presence of NBE had a tendency to develop fewer pressure ulcers on an APAM. Patients identified as being in need of prevention, based on the Braden Scale, appeared to develop more sacral pressure ulcers on an APAM.

PMID 15764622
F Biering-Sørensen, A K Schröder, M Wilhelmsen, B Lomberg, H Nielsen, N Høiby
Bacterial contamination of bath-water from spinal cord lesioned patients with pressure ulcers exercising in the water.
Spinal Cord. 2000 Feb;38(2):100-5.
Abstract/Text AIM: To evaluate the bacterial contamination of the water from the microflora of pressure ulcers in para- and tetraplegic patients, when they were exercising in water at 36 degrees C for half an hour.
MATERIAL: Twelve spinal cord lesioned (SCL) patients with ulcers participated, and six of the 12 SCL patients with healed ulcers constituted a control group.
METHODS: The evaluation was performed both with and without the ulcer covered with a moisture reactive occlusive dressing, DuoDERM. Bacterial samples were taken from the bath-water before and after the exercise programmes and additionally specimens were obtained from the ulcer, the patients skin and urine, and from the skin of the physiotherapist who exercised the patient. A similar procedure was carried out in the controls.
RESULTS: The bacteriologic analyses showed no significant difference in the contamination of the bath-water after exercising with or without DuoDERM covering the ulcers. In half of the patients DuoDERM loosened. After all exercise programmes with or without DuoDERM dressing the water was contaminated with facultative aerobic intestinal bacteria, ie E. faecalis and Enterobacteriaceae (E. coli, Klebsiella species, Proteus species, Enterobacter species). In nearly one-third of the exercise sessions the bath-water was contaminated with P. aeruginosa before starting, and after the exercise programmes one fourth of the ulcers were colonized with these pathogens.
CONCLUSION: The water specimen showed the bacteria from the intestine to be much more prominent than the bacteria coming from the ulcers. Thus the pressure ulcers were of minor importance for the bath-water and ought not to prohibit patients from the potential benefits of water exercise, but chlorination of the water in the training pool seems appropriate.

PMID 10762183
C Konya, H Sanada, J Sugama, M Okuwa, A Kitagawa
Does the use of a cleanser on skin surrounding pressure ulcers in older people promote healing?
J Wound Care. 2005 Apr;14(4):169-71.
Abstract/Text OBJECTIVE: To determine whether the use of a skin cleanser on the skin surrounding pressure ulcers helps to promote healing.
METHOD: The study was conducted over a two-year period in patients with stage II or more pressure ulcers. All subjects were at least 65 years of age and resident in a long-term care hospital. During the first year, skin was cleansed with normal saline. In year two, a pH-balanced cleanser was used. The healing times for the two methods were then compared.
RESULTS: Healing time was shorter in the group using the cleanser for every stage of ulcer, with an especially significant difference for stage II ulcers (p=0.002). Analysis using the Cox proportional hazards model found a 1.79-fold improvement in the healing rate of stage II ulcers when the surrounding skin was washed with the cleanser.
CONCLUSION: Cleaning the surrounding skin with a cleanser rather than normal saline promotes the healing of pressure ulcers.

PMID 15835228
M J Coggrave, L S Rose
A specialist seating assessment clinic: changing pressure relief practice.
Spinal Cord. 2003 Dec;41(12):692-5. doi: 10.1038/sj.sc.3101527.
Abstract/Text STUDY DESIGN: Description of a clinical service, evaluation of pressure relief practices.
OBJECTIVES: To describe a specialist seating assessment clinic and a change in clinical practice arising from its work.
SETTING: National Spinal Injuries Centre, Stoke Mandeville Hospital, UK.
METHODS: Retrospective review of the ischial transcutaneous oxygen measurements of 50 newly injured and chronic spinal cord-injured (SCI) individuals seen in a specialist seating assessment clinic. Tissue oxygenation was measured in the sitting position (loaded) and during pressure relief (unloaded).
RESULTS: Mean duration of pressure relief required to raise tissue oxygen to unloaded levels was 1 min 51 s (range 42 s-3 min 30 s).
CONCLUSION: These results confirmed the clinical perception that brief pressure lifts of 15-30 s are ineffective in raising transcutaneous oxygen tension (TcPO(2)) to the unloaded level for most individuals. Sustaining the traditional pressure relief by lifting up from the seat for the necessary extended duration is neither practical nor desirable for the majority of clients. It was found that alternative methods of pressure relief were more easily sustainable and very efficient.

PMID 14639449
H Dover, W Pickard, I Swain, D Grundy
The effectiveness of a pressure clinic in preventing pressure sores.
Paraplegia. 1992 Apr;30(4):267-72. doi: 10.1038/sc.1992.67.
Abstract/Text The role of a pressure clinic in reducing the incidence of pressure sores is described. Interface pressures are routinely measured to ensure that appropriate cushioning is provided. In patients most at risk, thermography is also valuable to ensure that the blood flow to the skin is not compromised. The implementation of such a clinic has proved successful and has resulted in a reduction of over 50% both in the incidence of sores and in the admission rate due to sores, when compared with studies from other spinal units.

PMID 1625896
J L Henderson, S H Price, M E Brandstater, B R Mandac
Efficacy of three measures to relieve pressure in seated persons with spinal cord injury.
Arch Phys Med Rehabil. 1994 May;75(5):535-9.
Abstract/Text This study compares three methods of pressure relief in seated spinal cord injured patients. One method consists of tipping the wheelchair back to 35 degrees, the second, tipping the wheelchair back to 65 degrees, and the third, leaning the subject forward with chest toward thighs. We evaluated dynamic pressure changes in each position using a new pressure mapping system. The greatest pressure relief over the ischial tuberosities was seen in the forward-leaning position. Significant pressure relief was shown in the 65 degrees backward tip. Only a minimal drop in ischial pressure was observed with a backward tip of 35 degrees indicating that the 35 degrees backward-tip position probably provides little protection against ischial skin breakdown.

PMID 8185445
M J Geyer, D M Brienza, P Karg, E Trefler, S Kelsey
A randomized control trial to evaluate pressure-reducing seat cushions for elderly wheelchair users.
Adv Skin Wound Care. 2001 May-Jun;14(3):120-9; quiz 131-2. doi: 10.1097/00129334-200105000-00008.
Abstract/Text OBJECTIVE: To determine if the use of pressure-reducing wheelchair cushions for elderly nursing home resident wheelchair users who are at high risk for developing sitting-acquired pressure ulcers would result in a lower incidence rate of pressure ulcers, a greater number of days until ulceration, and lower peak interface pressures compared with the use of convoluted foam cushions over a 12-month period. To determine the feasibility of conducting a subsequent full-scale definitive trial to evaluate the use of pressure-reducing seat cushions for elderly nursing home resident wheelchair users.
DESIGN: Randomized control trial
SETTING: 2200-bed skilled nursing facilities (1 suburban and 1 urban academic medical center)
PATIENTS: 32 male and female at-risk nursing home residents who were wheelchair users > or = 65 years of age. Participants had Braden Scale scores < or = 18, Braden Activity and Mobilitysubscale scores < or = 5, no sitting surface pressure ulcers, and a daily wheelchair sitting tolerance of more than 6 hours. All met criteria for using the ETAC Twin wheelchair.
INTERVENTIONS: Seating evaluation with pressure-mapping and subsequent seating prescription. Subjects were assigned to either a foam (n=17) or pressure-reducing cushion (n=15) group and weekly assessments of skin and pressure ulcer risk were made.
MAIN OUTCOME MEASURES: Incidence of pressure ulcers, days to ulceration, and peak interface pressure.
MAIN RESULTS: At a 95% confidence interval, a 2-tailed analysis showed no differences between the FOAM and pressure-reducing cushion groups for pressure ulcer incidence, total days to pressure ulcer, or initial peak interface pressure. Pressure-reducing cushions were more effective in preventing sitting-acquired (ischial) pressure ulcers (P<.005). Higher interface pressures were associated with a higher incidence of pressure ulcers (P<.001).
CONCLUSIONS: A definitive randomized control multicenter cushion trial is feasible with a sample size of 50 to 100 per study group. In the definitive trial, the definition of sitting-acquired pressure ulcers should be limited to lesions occurring over the ischial tuberosities.

PMID 11905977
David Brienza, Sheryl Kelsey, Patricia Karg, Ana Allegretti, Marian Olson, Mark Schmeler, Jeanne Zanca, Mary Jo Geyer, Marybeth Kusturiss, Margo Holm
A randomized clinical trial on preventing pressure ulcers with wheelchair seat cushions.
J Am Geriatr Soc. 2010 Dec;58(12):2308-14. doi: 10.1111/j.1532-5415.2010.03168.x. Epub 2010 Nov 10.
Abstract/Text OBJECTIVES: To determine the efficacy of skin protection wheelchair seat cushions in preventing pressure ulcers in the elderly nursing home population.
DESIGN: Clinical trial with participants assigned at random to a skin protection or segmented foam cushion. Two hundred thirty-two participants were recruited between June 2004 and May 2008 and followed for 6 months or until pressure ulcer incidence.
SETTING: Twelve nursing homes.
PARTICIPANTS: Nursing home residents aged 65 and older who were using wheelchairs for 6 or more hours per day and had a Braden score of 18 or less and a combined Braden activity and mobility score of 5 or less. Participants were recruited from a referred sample.
INTERVENTION: All participants were provided with a fitted wheelchair and randomized into skin protection (SPC, n=113) or segmented foam (SFC, n=119) cushion groups. The SPC group received an air, viscous fluid and foam, or gel and foam cushion. The SFC group received a 7.6-cm crosscut foam cushion.
MEASUREMENTS: Pressure ulcer incidence over 6 months for wounds near the ischial tuberosities (IT ulcers) were measured. Secondary analysis was performed on combined IT ulcers and ulcers over the sacrum and coccyx (sacral ulcers).
RESULTS: One hundred eighty participants reached a study end point, and 42 were lost to follow-up. Ten did not receive the intervention. There were eight (6.7%) IT ulcers in the SFC group and one (0.9%) in the SPC group (P=.04). There were 21 (17.6%) combined IT and sacral ulcers in the SFC group and 12 (10.6%) in the SPC group (P=.14).
CONCLUSION: Skin protection cushions used with fitted wheelchairs lower pressure ulcer incidence for elderly nursing home residents and should be used to help prevent pressure ulcers.

© 2010, Copyright the Authors. Journal compilation © 2010, The American Geriatrics Society.
PMID 21070197
T A Conine, C Hershler, D Daechsel, C Peel, A Pearson
Pressure ulcer prophylaxis in elderly patients using polyurethane foam or Jay wheelchair cushions.
Int J Rehabil Res. 1994 Jun;17(2):123-37. doi: 10.1097/00004356-199406000-00003.
Abstract/Text A significantly lower proportion of the patients in the Jay group (25%) experienced pressure ulcer formation during the three months of observation as compared to the foam group (41%). No statistically significant differences were found between groups on the location, severity, or healing duration of the pressure ulcers. Most lesions (65%) were limited to persistent erythema of intact skin, and healed in three to four weeks. Significantly higher proportions of patients in the Jay groups (7%) rejected their cushion because of discomfort as compared to foam (1%). The incidence of pressure ulcers was significantly higher among those patients who experienced peak interface pressures recorded at 60 mmHg or higher, had low Norton scores (< or = 11), or were malnourished.

PMID 7960335
Mohsen Makhsous, Fang Lin, Evan Knaus, Mary Zeigler, Diane M Rowles, Michelle Gittler, James Bankard, David Chen
Promote pressure ulcer healing in individuals with spinal cord injury using an individualized cyclic pressure-relief protocol.
Adv Skin Wound Care. 2009 Nov;22(11):514-21. doi: 10.1097/01.ASW.0000305495.77649.ee.
Abstract/Text OBJECTIVE: To evaluate whether an individualized cyclic pressure-relief protocol accelerates wound healing in wheelchair users with established pressure ulcers (PrUs).
DESIGN: Randomized controlled study.
SETTING: Spinal cord injury clinics.
PARTICIPANTS: Forty-four subjects, aged 18-79 years, with a Stage II or Stage III PrU, were randomly assigned to the control (n = 22) or treatment (n = 22) groups.
INTERVENTIONS: Subjects in the treatment group used wheelchairs equipped with an individually adjusted automated seat that provided cyclic pressure relief, and those in the control group used a standard wheelchair. All subjects sat in wheelchairs for a minimum of 4 hours per day for 30 days during their PrU treatment.
MAIN OUTCOME MEASURES: Wound characteristics were assessed using the Pressure Ulcer Scale for Healing (PUSH) tool and wound dimensions recorded with digital photographs twice a week. Median healing time for a 30% healing relative to initial measurements, the percentage reduction in wound area, and the percentage improvement in PUSH score achieved at the end of the trial were compared between groups.
RESULTS: At the end of 30 days, both groups demonstrated a general trend of healing. However, the treatment group was found to take significantly less time to achieve 30% healing for the wound measurement compared with the control group. The percentage improvement of the wound area and PUSH scores were greater in using cyclic seating (45.0 +/- 21.0, P < .003; 29.9 +/- 24. 6, P < .003) compared with standard seating (10.2 +/- 34.9, 5.8 +/- 9.2).
CONCLUSIONS: The authors' findings show that cyclically relieving pressure in the area of a wound for seated individuals can greatly aid wound healing. The current study provides evidence that the individualized cyclic pressure-relief protocol helps promote pressure wound healing in a clinical setting. The authors concluded that the individualized cyclic pressure relief may have substantial benefits in accelerating the healing process in wheelchair users with existing PrUs, while maintaining the mobility of individuals with SCI during the PrU treatment.

PMID 20026933
Mark J Rosenthal, Robert M Felton, Anne E Nastasi, Bruce D Naliboff, Judith Harker, Joseph H Navach
Healing of advanced pressure ulcers by a generic total contact seat: 2 randomized comparisons with low air loss bed treatments.
Arch Phys Med Rehabil. 2003 Dec;84(12):1733-42. doi: 10.1016/s0003-9993(03)00435-0.
Abstract/Text DESIGN: Randomized prospective cohort study.
SETTING: Long-term care facilities.
PARTICIPANTS: Two hundred seven subjects with stage III or IV pressure ulcers.
INTERVENTION: Two separate randomized control studies of advanced pressure ulcers that compared wound healing on 3 different support surfaces. Subjects were allocated to low air loss bed, upgraded bed overlay (only in study 1), or 4h/d sitting on an experimental generic total contact seat. The seat was designed using prosthetics principles aimed at distributing pressure off bony prominences onto less pressure-sensitive areas. Subjects were followed for 6 months or until they were totally healed.
MAIN OUTCOME MEASURES: Number of subjects who totally healed, time to total healing, and pressure ulcer status score after 4 weeks of treatment. Interface pressures and functional capacity were also measured at 4 weeks.
RESULTS: In study 1, 3 subjects worsened on the bed overlay condition and were withdrawn from the study. None worsened on low air loss or generic total contact seat. At 4 weeks in both studies, pressure ulcer status score was lowest for the generic total contact seat (P<.0001), compared with the other surfaces. Subject populations were similar, so to analyze total healing, results from both studies were combined. Total healing of pressure ulcers occurred as early as 4 weeks in some subjects using the generic total contact seat. Even at 8 weeks, total healing was primarily seen with use of that seat, on which interface pressures, function, and seating tolerance were best.
CONCLUSIONS: Faster healing and better function indicate that treatment using the generic total contact seat is superior to low air loss bed therapy, which is standard care for advanced pressure ulcers.

PMID 14669176
Nick Santamaria, Marie Gerdtz, Suzanne Kapp, Lauren Wilson, Amit Gefen
A randomised controlled trial of the clinical effectiveness of multi-layer silicone foam dressings for the prevention of pressure injuries in high-risk aged care residents: The Border III Trial.
Int Wound J. 2018 Jun;15(3):482-490. doi: 10.1111/iwj.12891. Epub 2018 Apr 10.
Abstract/Text Pressure injuries are prevalent in highly dependent aged care residents. This study investigated the clinical effectiveness of the application of the Mepilex Border Sacrum and Mepilex Heel dressings to prevent the development of facility-acquired pressure injuries. A total of 288 recently admitted residents were enrolled from 40 Australian nursing homes into a randomised controlled trial. Residents randomised to standard care (n = 150) received pressure injury prevention as recommended by international guidelines. Residents randomised to the intervention (n = 138) received standard pressure injury prevention care and had dressings applied to their sacrum and heels. Participants were comparable on demographic and physiological parameters. More residents in the control group developed pressure injuries than in the intervention group (16 vs 3, P = 0.004), and they developed more pressure injuries in total than residents in the intervention group. The results represent a relative risk reduction of 80% for residents treated with the dressings and for every 12 patients that we treated we prevented one pressure injury. Based on our findings, we conclude that the use of the Mölnlycke Mepilex Border Sacrum and Mepilex Heel dressings confers a significant additional protective benefit to nursing home residents with a high risk of developing a facility-acquired pressure injury.

© 2018 Medicalhelplines.com Inc and John Wiley & Sons Ltd.
PMID 29635842
D Peña Otero, D Vazquez Domínguez, L Hernanz Fernández, A Santano Magariño, V Jimenez González, J V García Klepzing, J V Beneit Montesinos
Preventing facial pressure ulcers in patients under non-invasive mechanical ventilation: a randomised control trial.
J Wound Care. 2017 Mar 2;26(3):128-136. doi: 10.12968/jowc.2017.26.3.128.
Abstract/Text OBJECTIVE: To comparatively assess the efficacy of four different therapeutic strategies to prevent the development of facial pressure ulcers (FPUs) related to the use of non-invasive mechanical ventilation (NIV) with oro-nasal masks in critically ill hospitalised patients.
METHOD: This randomised control trial was performed at the high dependency unit in the University General Hospital Gregorio Marañón in Madrid, Spain. Overall, 152 patients with acute respiratory failure were recruited. All patients were hospitalised and received NIV through oro-nasal masks. The Norton tool was used to evaluate the general risk of developing pressure ulcers (PUs). Subjects were divided into four groups, each of them receiving a different treatment. Tissue assessment and preventive care were performed by a member of the research team.
RESULTS: The incidence of FPUs was significantly lower in the group receiving a solution of hyperoxygenated fatty acids (HOFA) when compared with each of the other therapeutic strategies: direct mask (p=0.055), adhesive thin dressing (p=0.03) and adhesive foam dressing (p<0.001).
CONCLUSION: The application of HOFA on the facial skin in contact with the oro-nasal masks showed the highest efficacy in the prevention of NIV-related FPUs.

PMID 28277990
Nick Santamaria, Marie Gerdtz, Sarah Sage, Jane McCann, Amy Freeman, Theresa Vassiliou, Stephanie De Vincentis, Ai Wei Ng, Elizabeth Manias, Wei Liu, Jonathan Knott
A randomised controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: the border trial.
Int Wound J. 2015 Jun;12(3):302-8. doi: 10.1111/iwj.12101. Epub 2013 May 27.
Abstract/Text The prevention of hospital acquired pressure ulcers in critically ill patients remains a significant clinical challenge. The aim of this trial was to investigate the effectiveness of multi-layered soft silicone foam dressings in preventing intensive care unit (ICU) pressure ulcers when applied in the emergency department to 440 trauma and critically ill patients. Intervention group patients (n = 219) had Mepilex(®) Border Sacrum and Mepilex(®) Heel dressings applied in the emergency department and maintained throughout their ICU stay. Results revealed that there were significantly fewer patients with pressure ulcers in the intervention group compared to the control group (5 versus 20, P = 0·001). This represented a 10% difference in incidence between the groups (3·1% versus 13·1%) and a number needed to treat of ten patients to prevent one pressure ulcer. Overall there were fewer sacral (2 versus 8, P = 0·05) and heel pressure ulcers (5 versus 19, P = 0·002) and pressure injuries overall (7 versus 27, P = 0·002) in interventions than in controls. The time to injury survival analysis indicated that intervention group patients had a hazard ratio of 0·19 (P = 0·002) compared to control group patients. We conclude that multi-layered soft silicone foam dressings are effective in preventing pressure ulcers in critically ill patients when applied in the emergency department prior to ICU transfer.

© 2013 The Authors. International Wound Journal © 2013 Medicalhelplines.com Inc and John Wiley & Sons Ltd.
PMID 23711244
Cristiana Forni, Fabio D'Alessandro, Pina Gallerani, Rossana Genco, Andrea Bolzon, Caterina Bombino, Sandra Mini, Laura Rocchegiani, Teresa Notarnicola, Arianna Vitulli, Alfredo Amodeo, Guglielmo Celli, Patrizia Taddia
Effectiveness of using a new polyurethane foam multi-layer dressing in the sacral area to prevent the onset of pressure ulcer in the elderly with hip fractures: A pragmatic randomised controlled trial.
Int Wound J. 2018 Jun;15(3):383-390. doi: 10.1111/iwj.12875. Epub 2018 Jan 4.
Abstract/Text Hip fractures in the elderly are a serious problem for the health service due to the high rate of complications. One of these complications is pressure ulcers that, according to the literature, occur in 8.8% to 55% of patients and mainly arise in the sacral area. The present randomised controlled trial tests whether applying a new innovative multi-layer polyurethane foam dressing (ALLEVYN LIFE™), reduces the onset of pressure ulcers in the sacral area. From March to December 2016, 359 fragility hip fracture patients were randomly divided into 2 groups: 182 in the control group and 177 in the experimental group. Pressure ulcers occurred overall in 36 patients (10%): 8 patients (4.5%) in the experimental group compared to 28 (15.4%) in the control group: P = 0.001, relative risk 0.29 (95% CI 0.14-0.61) with NNT of 9 (95% CI 6-21). In the experimental group the onset of pressure ulcers occurred on average on the 6th day compared to the 4th day in the control group (HR 4.4). Using polyurethane foam is effective at reducing the rate of pressure ulcers in the sacrum in elderly patients with hip fracture. The adhesiveness of this device also enables costs to be kept down.

© 2018 The Authors. International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.
PMID 29314659
Marta Ferrer Solà, Joan Espaulella Panicot, Jacint Altimires Roset, Elisenda Ylla-Català Borè, María Moreno Susi
[Comparison of efficacy of heel ulcer prevention between classic padded bandage and polyurethane heel in a medium-stay hospital: randomized controlled trial].
Rev Esp Geriatr Gerontol. 2013 Jan-Feb;48(1):3-8. doi: 10.1016/j.regg.2012.04.008. Epub 2012 Nov 28.
Abstract/Text INTRODUCTION: The aim of the study is to determine the incidence of heel pressure ulcers (UPPT) and to compare the two systems for UPPT prevention: classic padded bandage and polyurethane heel.
MATERIAL AND METHODS: Prospective intervention study in a medium-long hospital stay of all people admitted that had no UPPT but had a risk of UPPT according to the Braden Scale or clinical judgment. The patients were randomized to prevention with classic padded bandage or polyurethane heel. The outcome variable was the incidence of UPPT for each study group, which was recorded every 15 days or when there were clinical changes.
RESULTS: Of the 940 patients evaluated, 409 with a mean age of 80.5 years and 59.1% women,were included in the study. Of these, 78% had Barthel score ≤30; 28.6% dementia; delirium 37.6%; 27.6% diabetes; and 19.6% other UPP. The overall incidence was 2.9% UPPT; 2.49% in the classic padded bandage and 3.37% in the polyurethane heel group (p=0.82).
CONCLUSIONS: No statistically significant differences were observed between the group with the classical dressing and the group with the polyurethane heel dressing. The use of multiple measures to prevent UPPT achieved a low incidence of these.

Copyright © 2011 SEGG. Published by Elsevier Espana. All rights reserved.
PMID 23199818
Kyoko Imanishi, Keisuke Morita, Mie Matsuoka, Hiroko Hayashi, Satsuki Furukawa, Fujiko Terashita, Eriko Moriya, Urara Kanesaki, Naoko Kinukawa, Yoshiaki Nose, Yoichi Moroi, Kazunori Urabe, Masutaka Furue
Prevention of postoperative pressure ulcers by a polyurethane film patch.
J Dermatol. 2006 Mar;33(3):236-7. doi: 10.1111/j.1346-8138.2006.00057.x.
Abstract/Text
PMID 16620238
Gojiro Nakagami, Hiromi Sanada, Chizuko Konya, Atsuko Kitagawa, Etsuko Tadaka, Yutaka Matsuyama
Evaluation of a new pressure ulcer preventive dressing containing ceramide 2 with low frictional outer layer.
J Adv Nurs. 2007 Sep;59(5):520-9. doi: 10.1111/j.1365-2648.2007.04334.x.
Abstract/Text AIM: This paper is a report of an evaluation of the effectiveness of a newly developed dressing for preventing persistent erythema and pressure ulcer development and improving the water-holding capacity without increasing the skin pH in bedridden older patients.
BACKGROUND: Shear forces and skin dryness play important roles in persistent erythema and pressure ulcer development. To eliminate these risks, we developed a dressing to reduce shear forces and improve the water-holding capacity. However, the effects of this dressing in clinical settings remain unknown.
METHOD: An experimental bilateral comparison study was conducted at a hospital in Japan in 2004 with 37 bedridden older patients at risk of pressure ulcer development. The dressing was randomly applied to the right or left greater trochanter for 3 weeks. No dressing was applied to the opposite side as a control. The skin was monitored weekly during the 3-week application for persistent erythema and pressure ulcer development. Skin hydration and pH were also assessed during the intervention and for 1 week after dressing removal.
FINDINGS: The incidence of persistent erythema was significantly lower in the intervention area than the control area [P = 0.007, RR 0.18 (95% CI: 0.05-0.73) and NNT 4.11 (2.50-11.63) ]. No pressure ulcers occurred in either the intervention or control area. Skin hydration increased significantly during dressing application and remained high after removal (P < 0.001) relative to the control area. Skin pH decreased significantly during the application (P < 0.001) but returned to control levels after removal (P = 0.38).
CONCLUSION: This safe and effective dressing can be used for patients with highly prominent bones and dry skin to prevent pressure ulcers.

PMID 17681081
M C Robson, L G Phillips, W T Lawrence, J B Bishop, J S Youngerman, P G Hayward, L D Broemeling, J P Heggers
The safety and effect of topically applied recombinant basic fibroblast growth factor on the healing of chronic pressure sores.
Ann Surg. 1992 Oct;216(4):401-6; discussion 406-8. doi: 10.1097/00000658-199210000-00002.
Abstract/Text The first randomized, blinded, placebo-controlled human trials of recombinant basic fibroblast growth factor (bFGF) for pressure sore treatment were performed. Three different concentrations of bFGF in five dosing schedules were tested for safety using hematology, serum chemistries, urinalysis, absorption, antibody formation, and signs of toxicity. Efficacy was evaluated by wound volumes, histology, and photography. No toxicity, significant serum absorption, or antibody formation occurred. In six of eight subgroups, there was a trend toward efficacy with bFGF treatment. When all subgroups were combined, comparison of the slopes of the regression curves of volume decrease over initial pressure sore volume demonstrated a greater healing effect for the bFGF-treated patients (p < 0.05). Histologically, bFGF-treated wound sections demonstrated increased fibroblasts and capillaries. More patients treated with bFGF achieved > 70% wound closure (p < 0.05). Blinded observers were able to distinguish differences in visual wound improvement between bFGF and placebo groups. These data suggest that bFGF may be effective in the treatment of chronic wounds.

PMID 1417189
S Meaume, D Vallet, M Nguyen Morere, L Téot
Evaluation of a silver-releasing hydroalginate dressing in chronic wounds with signs of local infection.
J Wound Care. 2005 Oct;14(9):411-9. doi: 10.12968/jowc.2005.14.9.26835.
Abstract/Text OBJECTIVE: To evaluate the clinical impact of using a silver-releasing hydroalginate dressing to minimise the risk of local infection in colonised chronic wounds.
METHOD: This was a randomised (stratification according to wound type) open-label multicentre comparative two-arm parallel-group study. Thirteen centres recruited 99 patients with either a venous leg ulcer or a pressure ulcer. None of the wounds required systemic antibiotics or were associated with lymphangitis and/or fever, but at least two of the following criteria had to be present: continuous pain; erythema; oedema; heat; and moderate to high levels of serous exudate. Patients were allocated to receive either a silver-releasing hydroalginate dressing (Silvercel, the test group) or a pure calcium alginate dressing (Algosteril, the control group). Wounds were assessed daily over 14 days to complete a modified ASEPSIS index to evaluate risk of infection, and then weekly for two additional weeks. A global wound severity score and area tracings were recorded weekly.
RESULTS: Fifty-one and 48 patients were randomised in the test and control groups respectively: 28 pressure ulcers and 71 venous leg ulcers. The total mASEPSIS score over 14 days did not differ significantly between groups: 95.4 +/- 62.2 and 104.2 +/- 72.8 in control and test groups respectively (p = 0.791). Of the patients who completed the total four-week study duration, four out of 38 (10.5%) in the control group and none of the 40 in the test group were treated with systemic antibiotics at the final visit (p = 0.053). According to the investigators, fewer wounds developed a clinical infection over the four-week follow-up in the test group (33% versus 46%; p = 0.223). Overall, the four-week closure rate was statistically greater in the test group (0.32 +/- 0.57cm2/day versus 0.16 +/- 0.40cm2/day; p = 0.024). Compared with baseline, the absolute decrease in wound severity score at week four was higher in the test group (-5.6 +/- 3.2 versus -4.1 +/- 4.3; p = 0.063); this was also true of the percentage reduction (-32 +/- 17% versus -23 +/- 25%; p = 0.034). Poor dressing acceptability and/or tolerability was noted in five out of 48 patients (10.4%) in the control group and in five out of 51 (9.8%) in the test group.
CONCLUSION: This study suggests that the use of silver-releasing dressings in the management of wounds at high risk of infection may have a clinically favourable influence on wound prognosis; the dressings also appeared to be well tolerated. However, the evaluation of these advantages in controlled clinical trials is complex and requires potent studies and the development of more specific endpoints than those currently used.

PMID 16240620
C Trial, H Darbas, J-P Lavigne, A Sotto, G Simoneau, Y Tillet, L Téot
Assessment of the antimicrobial effectiveness of a new silver alginate wound dressing: a RCT.
J Wound Care. 2010 Jan;19(1):20-6. doi: 10.12968/jowc.2010.19.1.46095.
Abstract/Text OBJECTIVE: To compare the efficacy and tolerability of a new ionic silver alginate matrix (Askina Calgitrol Ag) with that of a standard silver-free alginate dressing (Algosteril).
METHOD: Patients with locally infected chronic wounds (pressure ulcers, venous or mixed aetiology leg ulcers, diabetic foot ulcers) or acute wounds were eligible for this prospective, open-label, controlled and randomised trial. Patients were randomised to receive one of the two dressings for a two-week period. Criteria of efficacy were based on the evolution, from day 1 to day 15, of local signs of infection using a clinical score ranging from 0 to 18, and the evolution of the bacteriological status for each wound. The latter was determined by (blind) bacteriological examinations of results obtained from two biopsies performed at days 1 and 15. A three-point scale (deterioration, unchanged, improvement) was also used. Acceptability, usefulness and tolerance were also assessed.
RESULTS: Forty-two patients (20 women and 22 men, 68.9 +/- 18.8 and 66.5 +/- 15.7 years old respectively) were randomly assigned to receive either Askina Calgitrol Ag (n=20) or Algosteril (n=22). Most had chronic wounds such as pressure ulcers (57%) or venous or mixed aetiology leg ulcers and diabetic foot ulcers (29%); few had acute wounds (14%). Clinical scores of infection were comparable in both groups at inclusion, 8.9 +/- 2.4 and 8.6 +/- 3.2 in the Askina Calgitrol Ag group and the Algosteril group respectively (not significant), but decreased significantly in both groups at day 15, 3.8 +/- 2.9 in the Askina Calgitrol Ag group (p=0.001) and 3.8 +/- 3.4 in the Algosteril group (p=0.007). There was no significant difference between the two groups at day 15. Although there was also no significant difference in bacteriological status between the treatment groups, a trend in favour of Askina Calgitrol Ag was found for the relative risk of improvement, especially in patients who were not treated with antibiotics either at the beginning of the study or during it. No differences between groups were observed regarding local tolerance, acceptability and usefulness of the dressings.
CONCLUSION: The regression of local signs of infection, local tolerance, acceptability and usefulness were similar for the two dressings. However, Askina Calgitrol Ag improved the bacteriological status of the wounds. Further trials are required to show that it has a positive impact on the healing process.

PMID 20081570
David L Larson, Jacques A Machol, David M King
Vastus lateralis flap reconstruction after girdlestone arthroplasty: thirteen consecutive cases and outcomes.
Ann Plast Surg. 2013 Oct;71(4):398-401. doi: 10.1097/SAP.0b013e31824e29de.
Abstract/Text BACKGROUND: Pressure ulcers are found in approximately 4.7% of hospitalized populations. Up to 12.3% of hospitalized populations are at risk for developing these wounds. Decubitus ulcers are more common among the inpatient spinal cord injury group, with prevalence rates up to 30%. Surgical intervention is required when bone or the hip joint becomes involved. Girdlestone arthroplasty is a procedure that excises affected proximal femur and acetabular tissues; however, this resection typically results in a sizeable defect. The vastus lateralis flap has been extensively reviewed as a soft tissue filler option for this deficit.
MATERIALS AND METHODS: Thirteen consecutive cases from a single institution using the vastus lateralis muscle flap reconstruction after Girdlestone arthroplasty were reviewed. A search of internal records identified 11 patients with 13 vastus lateralis flap reconstructions performed immediately after Girdlestone arthroplasty for stage 4 ulcers or chronic, infected wounds affecting the hip joint. All patients involved were subjected to a similar standardized post-procedure activity schedule. Complications were defined as minor (superficial wound breakdown) or major (requiring further operative procedures to close the wound).
RESULTS: The majority of patients were male (91%) with a mean age of 43 years at the time of the procedure. All wounds involved the hip joint proper. Ninety-one percent of the patients had a history of spinal cord deficits. Thirty-one percent of the flaps had minor, superficial wound breakdown. Another 31% of the reconstructions required an additional operative procedure for major wound complications. One patient's wound was from multiple prior failed hip replacements. He eventually became ambulatory using a walker after reconstruction. Ultimately, 69% of the flaps healed satisfactorily without the need for further operative intervention.
CONCLUSIONS: Surgical debridement is required for chronic wounds involving the proximal femur, acetabulum, and hip joint. This review demonstrates that the use of a single-stage procedure including Girdlestone arthroplasty with immediate vastus lateralis muscle flap reconstruction is a practical treatment option for chronic wounds involving the acetabular joint. The use of a postoperative protocol and subsequent sitting schedule contributed to the success of these reconstructions. Overall, this procedure is applicable to spinal cord injury/pathology patients and to failed total hip arthroplasty patients for future assisted ambulation.

PMID 23407252
Masamitsu Kuwahara, Hideyuki Tada, Kumi Mashiba, Satoshi Yurugi, Hiroshi Iioka, Katsunori Niitsuma, Yukiko Yasuda
Mortality and recurrence rate after pressure ulcer operation for elderly long-term bedridden patients.
Ann Plast Surg. 2005 Jun;54(6):629-32. doi: 10.1097/01.sap.0000164465.40841.0b.
Abstract/Text We operated on 16 sacral pressure ulcers in elderly and long-term residential patients who were immobile as a result of cerebral vascular disease. The mean age of patients was 76 years. Eight ulcers were treated with local fascial flaps and 8 by simple closure. The follow-up period was from 1 to 4 years. Recurrence and mortality rates were examined retrospectively. In the 16 patients, recurrence occurred in 37.5%, and 43.8% died without recurrence. The recurrence rate was 37.5% for local fascial flaps and 37.5% for simple closure. Overall mortality was 68.8% in the follow-up period. Because postoperative death was common, we should not only focus on reducing local pressure but also pay attention to any underlying disease. Because of this high mortality rate, the least invasive procedure possible should be used. Because the recurrence rate of simple closure was the same as for local fascial flaps, simple closure should be considered as a reconstructive method.

PMID 15900149
Masahiro Tachi, Shinichi Hirabayashi, Yoshiyuki Yonehara, Gentaro Uchida, Takuya Tohyama, Hidenori Ishii
Topical negative pressure using a drainage pouch without foam dressing for the treatment of undermined pressure ulcers.
Ann Plast Surg. 2004 Oct;53(4):338-42.
Abstract/Text Topical negative pressure is gaining popularity as an acute and chronic wound management technique. In general, foam dressing is applied to the wound surface to maintain negative pressure. Due to the potential for clogging by the foam dressing, topical negative pressure cannot be used when there is a high volume of necrotic tissue or massive infection present. In this study, topical negative pressure was applied using a drainage pouch without any dressing. Topical negative pressure was applied to 8 patients with 9 pressure ulcers complicated by undermining. This approach was effective in the treatment of all 9 ulcers and allowed the wounds to be visualized while maintaining negative pressure. Since this technique can be performed without foam dressing, it can be used to treat early-stage infectious pressure ulcers in which there is a lot of necrotic tissue. CONCLUSION: Topical negative pressure without dressing is an extremely effective treatment of pressure ulcers complicated by undermining.

PMID 15385767
Tsukasa Isago, Motohiro Nozaki, Yuji Kikuchi, Takashi Honda, Hiroaki Nakazawa
Negative-pressure dressings in the treatment of pressure ulcers.
J Dermatol. 2003 Apr;30(4):299-305.
Abstract/Text Applying negative pressure to wounds may speed the formation of granulation tissue, decrease the amount of localized edema, increase blood flow, and accelerate healing. In the present study, we treated ten patients with stage IV chronic pressure ulcers using this negative pressure dressing technique. The long (A) and short (B) diameters of each ulcer were measured to determine size, and the vertical distance from the skin to the deepest point of the ulcer was measured to determine depth. Lesions were measured initially and at weekly intervals. The area of each lesion was taken to be 3.14 x A/2 x B/2 (cm(2)). When we compared the area of ulcer before and after the treatment, the area had been reduced in all cases, and the average reduction was 55.1%. The depth of ulcer also decreased in all cases, and the average reduction was 61.2%. Over the period of evaluation, the method was considered markedly effective in reducing the size and depth of ulcers.

PMID 12707466
Marcus B Wanner, Franz Schwarzl, Beni Strub, Guido A Zaech, Gerhard Pierer
Vacuum-assisted wound closure for cheaper and more comfortable healing of pressure sores: a prospective study.
Scand J Plast Reconstr Surg Hand Surg. 2003;37(1):28-33.
Abstract/Text Pressure sores are a common complication of patients with spinal injuries. The vacuum-assisted closure technique is widely used to induce and promote wound healing. We tested our clinical impression that pressure sores healed faster with vacuum-assisted closure, and compared it with the traditional wet-to-dry/wet-to-wet technique with gauze soaked in Ringer's solution changed three times a day. Consecutive patients with pressure sores were entered into the study. Two randomised groups of 11 patients each with pressure sores of the pelvic region were included. We found no difference in time to reach 50% of the initial wound volume between the two methods. The vacuum-assisted group took a mean (SD) of 27 (10) days and the traditional group 28 (7) days. The two methods were equally effective in forming granulation tissue, so one can profit from the other advantages of the vacuum-assisted treatment (reduced costs and improved comfort) knowing that the effect on the formation of granulation tissue is as good as with the traditional treatment.

PMID 12625392
Christian N Ford, Elaine R Reinhard, Daniel Yeh, David Syrek, Antonio De Las Morenas, Susan B Bergman, Steve Williams, Christine A Hamori
Interim analysis of a prospective, randomized trial of vacuum-assisted closure versus the healthpoint system in the management of pressure ulcers.
Ann Plast Surg. 2002 Jul;49(1):55-61; discussion 61.
Abstract/Text Twenty-eight patients with 41 full-thickness decubitus ulcers were randomized to compare the Vacuum-Assisted Closure device (VAC) with the Healthpoint System (HP) of wound gel products in promoting ulcer healing. A total of 22 patients with 35 full-thickness ulcers completed the 6-week trial of treatment, during which time 2 patients (10%) in the VAC group (N =20) and 2 patients (13%) in the HP group (N = 15) healed completely. The mean percent reduction in ulcer volume was 42.1% with HP and 51.8% with VAC (p = 0.46). The mean number of PMNs and lymphocytes per high-power field decreased in the VAC group and increased in the HP group (p = 0.13, p = 0.41 respectively). The mean number of capillaries per high-power field was greater in the VAC group (p = 0.75). There were 15 cases of biopsy-proven osteomyelitis underlying the ulcers; three (37.5%) improved with VAC and none improved with HP (p = 0.25). VAC promotes an increased rate of wound healing and favorable histological changes in soft tissue and bone compared with HP.

PMID 12142596
J Takahashi, O Yokota, Y Fujisawa, K Sasaki, H Ishizu, T Aoki, M Okawa
An evaluation of polyvinylidene film dressing for treatment of pressure ulcers in older people.
J Wound Care. 2006 Nov;15(10):449-50, 452-4.
Abstract/Text OBJECTIVE: To compare the effectiveness of polyvinylidene (PVL) food wrap as a dressing material versus conventional ointments and gauze dressings for pressure ulcers in patients aged 60 years or over.
METHODS: A prospective open controlled trial was conducted. The severity of pressure ulcers in both groups was evaluated using the DESIGN system. Scores were compared at baseline, four, eight and 12 weeks.
RESULTS: Twenty-five patients were treated with the PVL film (test) dressings and 24 with the conventional treatment (control). The test group showed greater improvement in DESIGN scores than the control group throughout the observation period, and the difference reached statistical significance at 12 weeks (p < 0.05). The incidences of local wound infection in the two groups were not statistically different (p > 0.999).
CONCLUSION: The PVL film dressing was more effective than conventional treatment in the management of severe pressure ulcers.

PMID 17124819
Noriyuki Aoi, Kotaro Yoshimura, Takafumi Kadono, Gojiro Nakagami, Shinji Iizuka, Takuya Higashino, Jun Araki, Isao Koshima, Hiromi Sanada
Ultrasound assessment of deep tissue injury in pressure ulcers: possible prediction of pressure ulcer progression.
Plast Reconstr Surg. 2009 Aug;124(2):540-50. doi: 10.1097/PRS.0b013e3181addb33.
Abstract/Text BACKGROUND: The concept of deep tissue injury under intact skin helps us understand the pathogenesis of pressure ulcers, but the best method for detecting and evaluating deep tissue injury remains to be established.
METHODS: Intermediate-frequency (10-MHz) ultrasonography was performed to evaluate deep tissue injury. The authors analyzed 12 patients (nine male patients and three female patients aged 16 to 92 years) who showed deep tissue injury-related abnormal findings on ultrasonography at the first examination and were followed up until the pressure ulcer reached a final stage.
RESULTS: The stage of ulcer worsened in six of 12 cases compared with baseline, and healed in the remaining six patients. The authors recognized four types of abnormal signs unique to deep tissue damage in ultrasonography: unclear layered structure, hypoechoic lesion, discontinuous fascia, and heterogeneous hypoechoic area. Unclear layered structure, hypoechoic lesion, discontinuous fascia, and heterogeneous hypoechoic area were detected at the first examination in 12, 10, seven, and five patients, respectively. Unclear layered structure and hypoechoic lesion were more commonly seen in pressure ulcers in deep tissue injury than the other features, but the follow-up study suggested that discontinuous fascia and heterogeneous hypoechoic area are more reliable predictors of future progression of pressure ulcers.
CONCLUSIONS: The use of intermediate-frequency ultrasound reliably identified deep tissue injury and was believed to contribute to prevention and treatment of pressure-related ulcers. The results suggest that specific ultrasonographic characteristics may predict which pressure ulcers will progress.

PMID 19644272
Eran Linder-Ganz, Nogah Shabshin, Amit Gefen
Patient-specific modeling of deep tissue injury biomechanics in an unconscious patient who developed myonecrosis after prolonged lying.
J Tissue Viability. 2009 Aug;18(3):62-71. doi: 10.1016/j.jtv.2009.02.004. Epub 2009 Mar 31.
Abstract/Text Deep tissue injury (DTI) is a severe pressure ulcer, characterized by necrotic tissue mass under intact skin. This communication integrates biomechanical analysis tools described in our previous publications, for reconstructing a "real-world" DTI case. A patient-specific finite element (FE) model was developed utilizing MRI of the thigh of a patient who was found unconscious after an estimated time of 3 days. During that time he lay down on the left side while in his left pocket there was a cellular phone. He developed left proximal thigh pain and swelling. MRI of his left thigh revealed deep muscle necrosis. To reconstruct this injury, previously reported injury threshold and damage law for muscle tissue were coupled into the FE-model. This allowed a time-dependent description of the size and shape of the DTI. We also simulated a hypothetical case for the same patient anatomy, where no phone was present. Though peak strains were only mildly (<1.2-fold) higher with the phone, the rigid phone structure "shifted" the sites of localized elevated strains substantially with respect to the simulation case where there was no phone present. Peak muscle stresses also did not differ much with/without the phone (<1.7-fold), but when the phone was present, considerably larger (4-fold) volumes of muscle and fat tissues were exposed to elevated (>10 kPa) stresses. By diverting the flow of internal tissue loads, the phone induced two stress concentrations in soft tissues, adjacent to the bone and adjacent to the phone. Since the phone induced elevated stresses in wider regions, it caused the DTI to develop and progress faster. The simulated DTI appeared in muscle tissue in proximity to the bone after approximately 1.5h, and within less than 10 additional minutes it reached the muscle-fat boundary. In conclusion, our biomechanical modeling tools could successfully reconstruct a "real-world" case of DTI, with reasonable similarity to the actual wound shape seen in the MRI. This case study also indicates that although both strain and stress measures can be considered adequate predictors of DTI, tissue stresses appear to perform better than strains.

PMID 19339183
Yunita Sari, Gojiro Nakagami, Ai Kinoshita, Lijuan Huang, Kohei Ueda, Shinji Iizaka, Hiromi Sanada, Junko Sugama
Changes in serum and exudate creatine phosphokinase concentrations as an indicator of deep tissue injury: a pilot study.
Int Wound J. 2008 Dec;5(5):674-80. doi: 10.1111/j.1742-481X.2008.00543.x.
Abstract/Text Deep tissue injury (DTI) is difficult to detect in the early phase. Creatine phosphokinase (CPK) as a muscle enzyme could represent a promising indicator of DTI. However, serum CPK levels reflect the systemic condition rather than the local wound environment. Wound exudates can be indicative of the local wound environment. This study aimed to investigate the usefulness of CPK levels in wound exudates as an indicator of DTI. Rats were divided into control, 6 hours 10-kg and 6 hours 20-kg loading groups. Serum samples were obtained before wounding, and at 8 and 12 hours, and 1, 2 and 3 days after wounding, while exudate samples were obtained on days 2 and 3. Serum CPK levels were markedly increased in the 10-kg and 20-kg groups at 8 and 12 hours after loading compared with the baseline value and control group, but decreased to the normal level on day 1. In both loading groups, exudate CPK levels were high on day 2 and decreased on day 3. Muscle necrosis was more severe in the 20-kg group than in the 10-kg group by histological examination. This is the first study to indicate the potential of CPK in wound exudates as an indicator of DTI.

PMID 19134069

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