Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 34

34

PRESSURE ULCER PREVENTION AND TREATMENT FOLLOWING SPINAL CORD INJURY

Treatment -
Nonsurgical
A comprehensive treatment plan begins with
an assessment of risk, health status, and status of
the pressure ulcer. The elements of the treatment
plan should address cleansing, debridement,
dressings, surgery, nutrition, and positioning and
support surface use.



Use diluted sodium hypochlorite ¼
strength to ½ strength solution for
wounds with heavy bioburden for
limited time only, until clinical evidence
of bioburden is resolved.



Use the following mechanical wound
cleansing techniques, to remove wound
debris, exudates, surface pathogens,
bacteria, and residue from topical
creams and ointments.
* 4-15 pounds per square inch (psi)
pressure irrigation with angiocatheter
attached to syringe, spray bottle, or
pulsatile lavage.

Creating a Physiologic Wound
Environment
Preparing the wound bed was a concept
introduced by Sibbald et al. (2006) who defined it
as the promotion of wound closure through
diagnosis and appropriate treatment of the cause,
attention to patient-centered concerns, and
correction of the systemic and local factors that
may be delaying healing.
The choice and use of wound cleansing
agents, dressings, forms of debridement and
adjunctive therapies are guided by the goal
of creating a physiologic wound environment
for healing. Wound management must focus on
the manipulation of the wound to create a
physiologic wound environment. This means
that any action/decision taken, type of dressing
used, use of adjunctive therapies, or combination
of therapies, should bring about a wound
environment that mimics the healthy and normal
function of the skin. Therefore the objectives
in creating a physiologic wound environment
consist of
(1) preventing and managing infection,
(2) cleansing the wound,
(3) removing nonviable tissue,
(4) maintaining appropriate level of moisture,
(5) eliminating dead space,
(6) controlling odor,
(7) eliminating or minimizing pain, and
(8) protecting the wound and periwound skin.
CLEANSE

14. Cleanse pressure ulcer with each dressing
change without harming healthy tissue on
the wound bed:


Use normal saline, sterile water,
pH-balanced wound cleansers, or
lukewarm potable tap water.

* Gentle scrubbing of the wound bed
with wet gauze.


Cleanse periwound skin with normal
saline, sterile water, pH-balanced skin
cleanser, or lukewarm potable tap water
with dressing changes.

(Scientific evidence-I, II, III, IV V; Grade of
,
recommendation-A; Strength of panel opinion-Strong)

Cleansing, a vital part of wound bed
preparation, is required to reduce bacterial
burden and to remove biofilm, devitalized tissue,
metabolic wastes, and residual topical agents that
can retard wound healing. There are no
randomized controlled trials regarding frequency
of cleansing or product use; however, expert
clinical opinion indicates that ulcers should be
cleansed prior to each dressing change without
causing chemical or mechanical trauma to the
wound (Barr, 1995).
Normal saline (0.9% NaCl), an irrigant
without a preservative, is recommended for
wound cleansing due to its noncytotoxic effects in
the wound. Although wound healing and infection
rates as well as bacterial burden have not been
found to be different when normal saline is used
as an irrigant as compared to tap water (Griffiths
et al., 2001; Svoboda, S.J. et al., 2008).
Although a preponderance of literature can
be found on antiseptic cytotoxicity in animal
models, (Lineaweaver et al. (1985); Mulliken et
al. (1980); Rodeheaver et al. (1982); Niedner and
Schopf (1986)) in vitro testing, and acute incised
wounds, a minimal amount of literature addresses
the effects of antiseptics on chronic human
wounds. Michael (1985) described pressure ulcer
healing in a small sample of individuals with SCI
treated with povidone-iodine. However, currently
antiseptic solutions are not recommended for
cleansing ulcers on a routine basis due to
cytotoxic effects, e.g., povodine iodine has been
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