PRESSURE ULCERS (BEDSORES, DECUBITUS ULCERS): COMPLICATION AND CLINICAL STRATEGY OF COMPLEX TREATMENT IN A PALLIATIVE CARE DEPARTMENT FROM THE POSITION OF CLINICAL EXPERIENCE

Abstract

Bedsores (syn. pressure ulcers – Decubitis ulcers) are caused by chronic compression, soft tissues ischemia and neurotrophic changes, inadequate nutrition and care, urinary and fecal incontinence, metabolic disorders due to the underlying disease; localized microcirculatory disorders; metabolic disorders. Modern scientific research is mainly aimed at developing strategies and methods for the treatment of pressure ulcers that have already formed, which is a local purulent-necrotic process. There is no clear consensus on the criteria for readiness of bedsores (which affects the outcome of surgery) for surgical treatment, which ultimately determines the length of the hospital care of palliative patient's. The aim of the work was to optimize the strategy of complex surgical treatment of stage III-IV bedsores and purulent complications in some palliative care clinic. A case of bedsores (pressure ulcers, decubitus ulcers) especially stage III-IV from palliative care department is being investigated. The total sample of the retro- and prospective analysis included the results of the complex treatment of 412 patients aged 40–93 years: 174 males and 238 females with soft tissue pressure ulcers. Stage I and II pressure ulcers were treated conservatively. In the presence of purulent complications, complex surgical sanation was performed. Clinical plans and treatment included adequate nutritional support, decompression of the area, sanation of pressure ulcers with antiseptics, including surgical intervention if necessary, adequate local and systemic infection control, and correction of background comorbidities. Based on author's clinical classification and the DOMINATE strategy, we created a simplified strategy, pathogenetically based and adapted for the treatment of pressure ulcers in a palliative care department with an adequate sequence of care and complex therapy. If it was impossible to simultaneously remove necrotic masses from the standpoint of monitoring the patient's general condition or additional/repeated necrosis formation, we used strategies of complex treatment according to standard clinical protocols, tactics of programmed resanitations/renecrectomies, and antibacterial therapy. Our proposed clinical classification criteria and adapted NODITE clinical strategy are simple and easy to use. Significant reduction of pain, signs of purulent necrotic inflammation and effective secondary prevention of complications constitute a set of criteria for effectiveness and economic feasibility, which, in our opinion, determines the possibility of introducing into clinical practice. Using the NODITE strategy, we found complete healing of complicated pressure ulcers within 45–60 days in half of the patients in the main group, while in the control group, this figure was only 35.7%. It has been shown that adequate local restriction and sanation of the problem area and the use of special anti-decubitus mattresses in palliative care departments contribute to the regression of the pathological process, granulation and marginal wound epithelialization. The strategy for the prevention, care and treatment of complicated bedsores includes N (Nutrition) – adequate nutritional support; O (Offloading) – offloading, decompression – external pressure reduction on the bedsores area by the use of special care products and orthopedic devices, which contributes to the proliferative phase of the wound process; D (Debridement) – opening, removal of pus and necrosis from the wound with precise step-by-step necro- and (if necessary) sequestrnecrectomy, with drainage of purulent cavity; I (infection) – the most appropriate combination of general antibiotic therapy and topical application of antiseptics and antibiotics; T (tissue management) – creating an appropriate environment in the wound, care, and stimulation of marginal epithelization; E (education) – providing appropriate care, monitoring the dynamics of the pressure ulcer wound process and correcting local venous and/or lymphatic stasis.