Nearly all pressure ulcers do not develop invasive, soft tissue infection simply because they drain freely. They all are, however, colonized with bacteria. It's rare for a pressure sore to become the cause of a fever in a paraplegic patient who presents to the emergency department. For the noninfected pressure sore, antibiotics are not required.
It is necessary, however, to eliminate soft tissue infection with a thorough evaluation from the ulcer just because a pressure ulcer should be free of infection prior to flap coverage. Any undrained abscess cavity should be incised, drained and packed. Grossly necrotic tissue should be debrided as it serves as a nidus for infection. Tetanus prophylaxis should be administered when necessary.
Underlying osteomyelitis is critical to identify prior to coverage. If a flap is placed over infected bone, there's a significantly higher risk of flap failure and other complications for example deep abscess or sinus tract formation. The diagnosis of osteomyelitis is accomplished using the measurement of the ESR level along with a core needle biopsy. The combination of the ESR more than 120 and a positive bone biopsy has the highest combined sensitivity and specificity.
A simple approach to biopsy is the Jamshidi core needle bone biopsy. Culturing the specimen is advantageous for identifying the particular organism, but since almost all bone is going to be colonized with bacteria, culture alone is not sufficient to make diagnosing of osteomyelitis. When the proper diagnosis of osteomyelitis is made, the patient should receive a 4-6 week course of intravenous antibiotics just before surgery.
Using MRI along with other imaging modalities 's time consuming and never cost effective. Furthermore, with the exception of MRI, many of these tests have a relatively low specificity. In academic centers in which MRI is readily available, it remains an option for diagnosing osteomyelitis.
There is a distinction between a pressure sore that is suitable for surgery, and a patient that is a good surgical candidate. Because of the high risk of recurrence and complications, a compliant patient is important to provide any possibility of treatment success. For those patients who will 't be compliant with the postoperative instructions, nonsurgical management should be considered. Many people with pressure ulcers are afflicted by depression and often feel socially isolated. This is especially true for paralyzed patients. A psychiatric evaluation can be of benefit in certain instances.
Most insensate patients are young and can achieve a sufficient nutritional status. In contrast, bed-bound, debilitated patients, especially the elderly, in many cases are malnourished. It is advisable to optimize nutritional status just before surgery. Many surgeons make use of a serum albumin level of 2.0 his or her minimum cut-off for surgery.
However, albumin includes a very short half life and is not an exact reflection of nutritional status. Serum prealbumin and transferrin levels are more accurate. Patients not able to obtain adequate caloric intake by themselves should receive supplemental enteral feeding with TPN being another choice.
In addition to adequate protein levels, wound healing requires zinc, ascorbic acid, along with other vitamins and minerals. Nutritionally depleted patients should get a daily multivitamin.
A number of health conditions, if not treated, will have a negative effect on the healing associated with a surgical flap. Diabetes must be managed aggressively, and blood sugars should be kept below 150. It's well known that uncontrolled blood sugars possess a significant negative effect on healing tissue.
Active infections such as urinary tract or pulmonary infections must be completely treated just before surgery. It's ill advised to use with an actively infected patient. Any individual with bacteremia should demonstrate a negative blood culture just before surgery.
For patients with severe peripheral vascular disease, a preoperative angiogram or magnetic resonance angiography should be considered. Since numerous flaps survive depending on circulation from the internal iliac vessels, it is important to rule out significant disease of those vessels. If indicated, a vascular bypass or stent/angioplasty should precede flap surgery.
Psychiatric conditions, especially depression, should be addressed. They are common in many pressure sore patients, especially the elderly. Since patient compliance is important to the successful healing of a pressure ulcer, it is vital to ensure that a psychiatric evaluation be performed when appropriate. In addition, patients who abuse alcohol or illicit drugs should undergo drug rehabilitation prior to surgery. There's a high risk of pressure sore recurrence among illicit drug users with spinal cord injuries.
Finally, patients taking steroids should receive vitamin A, (10,000 IU daily) to counteract the detrimental results of steroids on the wound healing process. Vit a may stimulate macrophages that have been inhibited through the steroids. Furthermore, some evidence shows that vitamin A reverses the inhibitory effects that steroids have on TGF-beta.
Our website is not responsible for the information contained by this article. Articleinput.com is a free articles resource thus practically any visitor can submit an article. However if you notice any copyrighted material, please contact us and we will remove the article(s) in discussion right away.
Note: This article was sent to us by: Steven J. Miller at 02092011
1. How to maintain a healthy water and electrolyte balance
All articles are property of their respective authors. Please read our Privacy Policy!
© 2009 ArticleInput.com.
Partners: Damenmode