SELECTED
ABSTRACTS
Technological
Advances in Pressure Ulcer Prevention – how close are we
to producing an objective clinical monitoring system?
Dan Bader DSc
Department of Engineering, Queen Mary University of London, Mile
End Road, London E1 4NS, UK, and Department of Biomedical Engineering,
Eindhoven University of Technology, The Netherlands. D.L.Bader@qmul.ac.uk
Despite considerable efforts to prevent pressure ulcers, prevalence
figures still remain an unacceptably high burden to the individual
and modern society as a whole. In addition to the traditional
view involving pressure-induced ischaemia, other theories associated
with the pathophysiological response to mechanical loading have
been proposed (Bouten et al., 2003). These include impaired interstitial
fluid flow (Reddy et al., 1981) and lymphatic drainage (Miller
and Seale 1981), sustained deformation of cells (Wang et al.,
2005) and reperfusion injury (Peirce et al., 2000). In addition,
recent interest has identified the susceptibility of underlying
muscle tissue to breakdown, with particular focus on deep tissue
injury.
In order to minimise the clinical problem, objective monitoring
needs to be available to identify both conditions at the patient-support
interface which can lead to tissue breakdown and susceptible individuals.
Techniques have largely focused on measurements of interface pressures
and/or soft tissue viability or status (Knight et al., 2001).
They largely reflect the conditions within the skin tissues and
their applications will be critically evaluated. Other technologies,
however, are now available, which can image the entire soft tissue
composite down to underlying bony prominences (Stekelenburg et
al., 2006), evaluate damage at the cellular level and predict
the local mechanical environment within the tissues. These techniques
will be discussed, with emphasis on their potential in providing
monitoring systems for the clinician.
Relevant References
Bouten CVC, Oomens CWJ, Baaijens FPT and Bader DL (2003) Arch.
Phys. Med. Rehabil. 84: 616–9.
Knight SL, Taylor RP, Polliack AA and Bader DL (2001) J. Applied
Physiology 90: 2231–37.
Miller GE and Seale J (1981) Lymphology 14: 161–6.
Peirce SM et al. (2000) Wound Rep. and Regen. 8: 68–76.
Reddy NP et al. (1981) J. Biomechanics 14: 879–81.
Stekelenburg A, Oomens CWJ, Strijkers GJ, de Graaf LAHJ, Nicolay
K. and Bader, DL (2006) J. Applied Phys., 28, 331–8
Wang Y-N, Bouten CVC, Lee DA and Bader DL (2005) Proc. Inst. Mech.
Eng. Part H Engineering in Medicine, 219, 1–12.
Patient
stories of living with pressure ulcers: the impact on practice
and implications for further European research.
Hopkins A, Dealey C, Bale S, Defloor T and Worboys F.
The EPUAP Phenomenology Group
This paper discusses the findings of the EPUAP funded phenomenological
study that investigated the lived experience of older people with
pressure ulcers. It provides a synopsis of the key themes to emerge
and focuses on the impact of the findings on patient care and
equipment provision; the three core themes were pressure ulcers
produce endless pain; pressure ulcers produce a restricted life;
coping with a pressure ulcer.
Background:
Pressure ulcers are known to be a significant health burden, but
little is known of the impact on the quality of life of the sufferer.
They mainly affect older people, and this is a neglected group
in previous studies of this topic.
Methods:
A Heideggerian phenomenological approach was used and patients
were recruited if they were over 65 years of age and had a grade
3 or 4 pressure ulcer that had been present for more than a month.
Patients were recruited from multiple centres but the data were
analysed centrally. The study took place in 2003–2004.
Findings:
Analysis of the transcripts revealed three main themes, all with
associated sub themes: pressure ulcers produce endless pain; pressure
ulcers produce a restricted life; coping with a pressure ulcer.
The endless pain theme had four subthemes: constant presence,
keeping still, equipment pain and treatment pain. Some patients
found that keeping still reduced their pain. Several patients
also reported that pain was exacerbated by their pressure relieving
equipment and at dressing change. There were three sub themes
for the restricted life theme: impact on self, impact on others
and consequences. Patients found that the pressure ulcer restricted
their activities and had an impact on their families. In addition,
for some, the restrictions delayed their rehabilitation. To cope
with their pressure ulcers, patients developed ways of accepting
their situation or comparing themselves with others.
Conclusions:
Although a pilot, this study has produced a wealth of data that
demonstrates the impact of pressure ulcers on people. While a
larger study is required to obtain a European perspective, it
is still reasonable to conclude that the issues of pain and restrictions
should be considered in the development of pressure ulcer treatment
and prevention guidelines.
Reference (complete article):
Hopkins A, Dealey C, Bale S, Defloor T and Worboys F (2006). Patient
stories of living with a pressure ulcer,
Journal of Advanced Nursing, 56 (4), 1–9.
Evolution
or Revolution? Adapting to Complexity in Wound Management
Smith & Nephew Symposium (two papers)
Congress Centre, Berlin
Thursday 31 August 2006, 4.15 – 6.00 pm
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Why
we need more than one approach in pressure ulcer management
Professor Keith Harding
Cardiff Medicentre, Wales
It is very tempting to look for a single approach that we can
rely on to provide us with all the answers that we need in
the management of all wounds, including pressure ulcers. Wound
Bed Preparation comes close as an educational tool, because it
is in itself multifactorial, but those of us who have looked for
a single system or method of treatment for wounds have invariably
been disappointed. On the technical side, there has recently been
a focus on single interventions, and the possibilities that they
provide for healing a variety of wounds. Although some of these
are very promising, we must be careful of reductive solutions
that don’t sufficiently take into account all the other
factors in wound management.
To select appropriate treatment protocols, including appropriate
dressings, a whole host of factors must be considered; the wound
itself needs to be monitored and assessed, and the location, size,
severity, cause, stage of progress and type of chronic wound will
all have an impact on the decisions made regarding the type of
care and treatments used. The wound is only one part of a many
tiered treatment regime. The general health, nutrition, age and
co-morbidities of the patient naturally need to be taken into
account, as well as the appropriate treatment goals for that person.
Our patients’ immediate environments and the ranges of health
services available to them will also affect their wound care regimes,
and as clinicians we must all be aware of the facilities (and
budgets) that we have available to provide the best outcomes for
our patients.
During my presentation I will suggest some approaches that are
worth considering in conjunction with others. I will also suggest
that this need for multiple approaches highlights the need for
tools and technologies that are themselves highly adaptive and
multifactorial.
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Considerations in appropriate dressing
design
Professor Keith Harding
Cardiff Medicentre, Wales
Over the past four decades the importance of moisture control
through effective exudate management has become more apparent.
The moist wound healing paradigm has had a huge influence in dressing
design, but as a greater understanding of the other underlying
factors in the wound environment has emerged, we need to expect
a dressing to demonstrate a level of adaptability that will suit
a variety of wound factors.
Protection of the wound, good wear time and ease of fixation are
naturally important technical features, along with the ability
to adapt to wound size, position, shape and depth. On the biochemical
side, research has shown that exudate from chronic and acute wounds
are quantitatively and qualitatively different, with very different
cellular and biochemical events underlying them. Where excess
exudate can harbour infection, the increased levels of white blood
cells can also keep infection under control. Dressing design should
include a moist wound interface, while allowing transpiration
of excess fluid to achieve good moisture balance. This can reduce
pain levels, address infection and restore a good wound healing
environment. Dressings
should also prevent exudate from seeping on to healthy areas of
skin and should provide an effective barrier against infection
from external sources.
As a result I will discuss the importance of total exudate management
in terms of the combination of fluid absorption and moisture vapour
transpiration. I will also suggest that adaptability in this area
is becoming increasingly important, along with mechanical flexibility
and antimicrobial barrier protection, and that dressings may be
more inclined to fail where these features have been overlooked.
Antibacterial activity of positive and
negative polarity high voltage pulsed current (HVPC) on six typical
gram positive and gram negative bacterial pathogens of chronic
wounds.
Gerromed Symposium, Paper One Georg Daeschlein1, Ojan Assadian2,
Christina Meinl2, F Ney1 and Axel Kramer1
1 Institute of Hygiene and Environmental Medicine, Ernst- Moritz-Arndt
University, Greifswald, Germany
2 Department of Hygiene and Medical Microbiology, Medical University
of Vienna, Vienna, Austria
Introduction:
Based on increased blood flow, protein denaturation and stimulation
of cellular defence, an antibacterial effect of electrical stimulation
ES is to be expected. Although the antibacterial effect of ES
already has been demonstrated in vitro, little attention has been
paid to the direct antibacterial effect of changing polarity of
the applied current.
Method:
Using the WoundEL®-System, the gram negatives E. coli, P.
aeruginosa, K. pneumoniae and the gram positives S. aureus, S.
epidermidis, E. faecium were tested against positive and negative
polarity HVPV (42 mA, pulse rate of 128 Hz). The electrodes were
cut into pieces of 2.5cm x 2.5 cm.
To simulate a wound, sterile 100% cotton patches 2.5 cm x 2.5
cm (6.25 cm2) were used. 300 µl of each bacterial suspension
(1.2 x 104 colony forming units/ml) were pipetted onto a cotton
patch and placed onto a 58 cm x 40 cm x 4
mm sized sterile stainless steel (V4A) panels. The cotton patches
were covered with the electrodes and a sterile glass slide to
improve contact between the electrode and the cotton patches (exposure
30 min).
Results:
All bacteria were significantly (P < 0.01) reduced by ES. The
reduction differed significantly (P = 0.02) between positive and
negative polarity, with the highest log10 reduction factor (RF)
achieved with positive polarity. Using positive polarity, the
maximum RF was measured for Escherichia coli (median log10 RF
0.83; 25th percentile 0.59, 75th percentile 0.98), the lowest
for Staphylococcus epidermidis (median log10 RF 0.20; 25th percentile
0.17, 75th percentile 0.24). Yet, there was no significant difference
with positive ES against gram positive (P = 0.35) or gram negative
(P = 0.71) organisms.
Summary:
It can be assumed that the microbicidal efficacy will additionally
directly support the in vivo induced indirect antibacterial effects.
Clinical experience with a new topical device WoundEL_
used in geriatric patients with chronic wounds
Gerromed Symposium, Paper Two
R.-J. Schulz, M. Azzarro and E. Steinhagen-Thiessen
Charité, Dept for Geriatric Medicine, Humboldt-University
Berlin, Germany
Introduction:
Geriatric patients usually present multmorbid clinical status.
In this context the treatment of chronic wounds is very costly,
demanding lengthy hospital stays or specialized home care. In
general, therapies of chronic wounds cannot be completed in hospital
but have to be continued in the ambulatory care system.
The aim of this clinical study is to prove the applicability of
a new method of wound treatment by electrical stimulation. This
might be of special interest because several factors like malnutrition,
chronic circulatory disorder and immobility hinder regular wound
healing.
Methods:
So far fifteen patients with different types of chronic wounds
(decubital ulcer, gangrene, diabetic foot syndrome) are treated
over a time period of seven days to eight weeks. Utilized was
a WoundEL-device from GerroMed company which works on a low-frequency
pulsed direct-current (PDC). According to the protocol, patients
were treated twice a day by a 30 to 42 mA PDC over thirty minutes
with a frequency of 128 Hz. The range of age was 65–98 years,
mean age was 79 years. On average, seven diagnoses were documented
beside the chronic wound healing problem. All wounds were documented
by digital imaging. Microbiological tests were performed on day
one and once a week in the follow-up.
Results:
Up to now, all therapies were well tolerated. Fifty percent of
the patients uttered local misperception in currents over 30 mA.
Microbiological control did not indicate any infected wounds.
With negative polarity all necrosis were debrided and wound bed
preparation was performed without problems. Even large wound areas
(7 x 12 cm) were treated without difficulty.
Time correlation between wound therapy and different wound types
could not be calculated because of the small number of patients
so far. Quite impressive was the wound healing in one case with
a history of skin transplantation, vascularity deficits and large
necrotic tissue fraction. Occlusive wound dressing and wound care
was easy to perform without traumatic handling or pain induction.
Summary:
In our opinion this new approach indicates a simple and fast way
of wound therapy by electrical stimulation. This might be of interest
in treatment of multimorbid patients with several reasons for
complications. So far this method is a safe and atraumatic way
of therapy and was well tolerated even by patients with dementia.
Possible misconception was eliminated by accurate adjustment of
the mA dosage.
Because of this new therapy, hospital stay could be dramatically
reduced and therapy easily continued in ambulatory care. From
the viewpoint of cost reduction this might be a quite convincing
concept for the future. Above all, improvement of life quality
could be demonstrated by earlier release from hospital and retain
from painful treatment.
Figures
1 to 3 (above) demonstrate the time course of wound healing indicating
the change from necrotic tissue
(Figure 1) at day 0, to accelerated tissue recovery with vasoformation
at day 10 (Figure 2)
to well reconstituted epithelial areas at day 20 (Figure 3).
