今日の臨床サポート

褥瘡

著者: 立花隆夫 大阪赤十字病院 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:2019/10/26
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)
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要とな
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契
  1. 閲覧にはご契約が 必要となりま す。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となり
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。
※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、実際の保険適用の査定において保険適用及び保険適用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用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:
立花隆夫 : 特に申告事項無し[2021年]
監修:戸倉新樹 : 講演料(田辺三菱,サノフィ,マルホ,協和キリン),研究費・助成金など(ノバルティス,レオファーマ)[2021年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)。

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。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

著者: Pedro L Pancorbo-Hidalgo, Francisco Pedro Garcia-Fernandez, Isabel Ma Lopez-Medina, Carmen Alvarez-Nieto
雑誌名: 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  J Adv Nurs. 2006 Apr;54(1):94-110. doi: 10.1111/j.1365-・・・
著者: Enid Kwong, Samantha Pang, Thomas Wong, Jacqueline Ho, Xue Shao-ling, Tao Li-jun
雑誌名: 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  Appl Nurs Res. 2005 May;18(2):122-8. doi: 10.1016/j.apn・・・
著者: Zena E H Moore, Seamus Cowman
雑誌名: 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  Cochrane Database Syst Rev. 2008 Jul 16;(3):CD006471. d・・・
著者: Rebecca J Stratton, Anna-Christina Ek, Meike Engfer, Zena Moore, Paul Rigby, Robert Wolfe, Marinos Elia
雑誌名: 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  Ageing Res Rev. 2005 Aug;4(3):422-50. doi: 10.1016/j.ar・・・
著者: G Langer, G Schloemer, A Knerr, O Kuss, J Behrens
雑誌名: 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  Cochrane Database Syst Rev. 2003;(4):CD003216. doi: 10.・・・
著者: Elizabeth McInnes, Sally Em Bell-Syer, Jo C Dumville, Rosa Legood, Nicky A Cullum
雑誌名: 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  Cochrane Database Syst Rev. 2008 Oct 8;(4):CD001735. do・・・
著者: N Cullum, E McInnes, S E M Bell-Syer, R Legood
雑誌名: 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  Cochrane Database Syst Rev. 2004;(3):CD001735. doi: 10.・・・
著者: JoAnne Whitney, Linda Phillips, Rummana Aslam, Adrian Barbul, Finn Gottrup, Lisa Gould, Martin C Robson, George Rodeheaver, David Thomas, Nancy Stotts
雑誌名: Wound Repair Regen. 2006 Nov-Dec;14(6):663-79. doi: 10.1111/j.1524-475X.2006.00175.x.
Abstract/Text
PMID 17199832  Wound Repair Regen. 2006 Nov-Dec;14(6):663-79. doi: 10.・・・
著者: Madhuri Reddy, Sudeep S Gill, Paula A Rochon
雑誌名: 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  JAMA. 2006 Aug 23;296(8):974-84. doi: 10.1001/jama.296.・・・
著者: Tom Defloor, Dirk De Bacquer, Maria H F Grypdonck
雑誌名: 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  Int J Nurs Stud. 2005 Jan;42(1):37-46. doi: 10.1016/j.i・・・
著者: Katrien Vanderwee, Maria H F Grypdonck, Tom Defloor
雑誌名: 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  Age Ageing. 2005 May;34(3):261-7. doi: 10.1093/ageing/a・・・
著者: F Biering-Sørensen, A K Schröder, M Wilhelmsen, B Lomberg, H Nielsen, N Høiby
雑誌名: 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  Spinal Cord. 2000 Feb;38(2):100-5.
著者: C Konya, H Sanada, J Sugama, M Okuwa, A Kitagawa
雑誌名: 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  J Wound Care. 2005 Apr;14(4):169-71.
著者: M J Coggrave, L S Rose
雑誌名: 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  Spinal Cord. 2003 Dec;41(12):692-5. doi: 10.1038/sj.sc.・・・
著者: H Dover, W Pickard, I Swain, D Grundy
雑誌名: 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  Paraplegia. 1992 Apr;30(4):267-72. doi: 10.1038/sc.1992・・・
著者: J L Henderson, S H Price, M E Brandstater, B R Mandac
雑誌名: 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  Arch Phys Med Rehabil. 1994 May;75(5):535-9.
著者: Masahiro Tachi, Shinichi Hirabayashi, Yoshiyuki Yonehara, Gentaro Uchida, Takuya Tohyama, Hidenori Ishii
雑誌名: 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  Ann Plast Surg. 2004 Oct;53(4):338-42.
著者: Tsukasa Isago, Motohiro Nozaki, Yuji Kikuchi, Takashi Honda, Hiroaki Nakazawa
雑誌名: 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  J Dermatol. 2003 Apr;30(4):299-305.
著者: Marcus B Wanner, Franz Schwarzl, Beni Strub, Guido A Zaech, Gerhard Pierer
雑誌名: 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  Scand J Plast Reconstr Surg Hand Surg. 2003;37(1):28-33・・・
著者: Christian N Ford, Elaine R Reinhard, Daniel Yeh, David Syrek, Antonio De Las Morenas, Susan B Bergman, Steve Williams, Christine A Hamori
雑誌名: 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  Ann Plast Surg. 2002 Jul;49(1):55-61; discussion 61.
著者: J Takahashi, O Yokota, Y Fujisawa, K Sasaki, H Ishizu, T Aoki, M Okawa
雑誌名: 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  J Wound Care. 2006 Nov;15(10):449-50, 452-4.
著者: Noriyuki Aoi, Kotaro Yoshimura, Takafumi Kadono, Gojiro Nakagami, Shinji Iizuka, Takuya Higashino, Jun Araki, Isao Koshima, Hiromi Sanada
雑誌名: 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  Plast Reconstr Surg. 2009 Aug;124(2):540-50. doi: 10.10・・・
著者: Eran Linder-Ganz, Nogah Shabshin, Amit Gefen
雑誌名: 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  J Tissue Viability. 2009 Aug;18(3):62-71. doi: 10.1016/・・・
著者: Yunita Sari, Gojiro Nakagami, Ai Kinoshita, Lijuan Huang, Kohei Ueda, Shinji Iizaka, Hiromi Sanada, Junko Sugama
雑誌名: 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  Int Wound J. 2008 Dec;5(5):674-80. doi: 10.1111/j.1742-・・・

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