Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 53

CLINICAL PRACTICE GUIDELINE

and education should be a part of pre-operative
planning in the same vein as the aphorism that
has stood the test of time, that discharge planning
begins on hospital admission.
P O S T O P E R AT IVE POS IT IONING A ND
S U P P O RT S U RFA CE S

It is important that no pressure be applied to
the operative site after surgery as this decreases
vascular perfusion and blood supply. As with all
wounds, healing surgical incisions are
hypermetabolic and require a sufficient supply of
oxygen and nutrients. Premature tissue loading
greatly increases the risk of dehiscence and poor
healing. In addition, the application of shear and
friction across healing incisions can overcome
their burst strength and directly cause a
dehiscence. The selection of post-operative
support surface used during the period of bed
rest should be based on the modern concepts of
immersion and envelopment to maximize
pressure distribution. Traditionally an air-fluidized
bed has been used. A more recently developed
fluid immersion simulation air mattress system
may prove equally effective, however, there is no
high-level evidence supporting the use of any
specific support surface (Tchanque-Fossuo et al,
2011). The postoperative patient should be
maintained on a turning regimen that does not
apply pressure to the operative site. While in bed,
the head of the bed should not be elevated by
more than 15 degrees in people recovering from
sacral or ischial repairs since this position
increases the risk of shear on the repaired ulcer
site. Prone positioning has been suggested in the
past, but is currently used less often given the
advances in bed and mattress technology, and
should only be used with consideration of airway
maintenance and ventilation which are both
problematic with immersive surfaces.
P O S T O P E R AT IVE ME DICA L CA RE

The use of constipating medications
administered in the acute post-op period and a
low-fiber diet to avoid fecal contamination of the
surgical site has been described in the past by a
few centers (Black and Black, 1987; Rubayi et al.,
1990), but is not in widespread use. Caregivers
should be vigilant to the development of
postoperative ileus with regular bowel regimens
restarted as soon as possible.
The use of prophylactic antibiotics was
commonly advocated in the past; however,
modern antibiotic therapy mandates culturedirected selection. Antibiotics may be used in
conjunction with surgical management of
pressure ulcers. Adequate wound debridement
prior to flap coverage should excise all potential

niduses of infection (Bauer, 2008). A single dose
of a broad spectrum antibiotic with coverage of
skin flora and enteric bacteria (e.g., piperacillin/
tazobactam) should be used within two hours of
initial skin incision (Tchanque-Fossuo, 2011).
Post-operative antibiotic therapy should be
reserved for cases of osteomyelitis proven by
bone biopsy obtained after bone debridement
immediately prior to flap coverage with an
appropriate culture-specific antibiotic (Larson et
al., 2011; Larson et al., 2012).
Deep venous thrombosis prophylaxis should
be initiated consistent with clinical practice
guidelines for SCI. However, a recent article
(Rimler et al., 2011) analyzed a 5-year, 260 case
series in which no pre-operative DVT prophylaxis
was given for patients with chronic SCI and found
that there was a zero incidence of peri-operative
DVT. This is important because chemical DVT
prophylaxis can increase the risk of bleeding and
hematoma associated with surgical flaps due to
the large tissue surface areas involved with flap
mobilization.
Indwelling urinary catheters are frequently
used in the post-op period to prevent
contamination of the surgical site by urine.
Persons with higher levels of SCI are at high risk
for pulmonary complications including atelectasis
and pneumonia in this period of enforced bed rest
and chest percussion and postural drainage as
well as measures to maintain alveolar expansion
such as incentive spirometry should be
implemented in appropriate at risk individuals.
POSTOPERATI VE MOBI LI ZATI ON

Experienced centers reporting the best
outcomes for pressure ulcer surgery follow a
standardized protocol or clinical pathway in
keeping with the common general theme for
surgical repair of pressure ulcers (Bauer, 2008;
Keys et al., 2010; Tchanque-Fossuo et al., 2011;
Larson et al., 2012). Again, while the specifics
may differ, these reported post-flap protocols
involve a period of strict bed rest immediately
after surgery and passive range of motion when
healing permits, followed by a graduated and
progressive sitting regimen with a seating
assessment.
The length of time of strict bed rest is not
completely arbitrary, but rather based on the time
course of the healing of primarily closed wounds
taking into account tensile strength and flap
vascularity. The healing of flaps also involves the
formation and maturation of new vascular
anastomoses between the flap and the recipient
bed, with 90% of final flap circulation achieved
after 3 weeks. In the past, persons who had

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Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

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