European Pressure Ulcer Advisory Panel

Managing the Pressure Ulcer - a Holistic Approach

Dr. George W. Cherry

Oxford International Wound Healing Foundation,
Oxford UK

The mission statement of the European Pressure Ulcer Advisory Panel is 'to provide the relief of persons suffering from, or at risk of pressure ulcers, in particular through research and education of the public'. The aim of this symposium is demonstrate how this objective fits in with the holistic approach of pressure ulcer management in the 21st century.

Today pressure relief systems such as the low air loss pressure relief mattress with pulsation therapy (TheraKair®Visio) have been designed to not only prevent pressure ulcer development by managing oedema and blood supply through pulsation therapy, but also by providing an ideal material for managing the skin's microclimate. Both of these aspects of prevention and enhanced healing lead to an improvement in the patient's quality of life. Therefore pressure relief systems like TheraKair® based on research principles are extremely important in prevention and healing.

Enhancement of healing of chronic wounds including pressure ulcers after relief of pressure of the wounds is just as important and obviously one therapy, that of topical negative pressure (V.A.C.®), is a proven method of enhancing healing. At least twelve randomised control trials on the V.A.C.® which in itself is a major feat for any type of wound healing therapy have been published. The mechanism of how the system works has been shown to act by having a transducer effect through the negative pressures which stimulate different aspects of the healing cascade. The uniqueness of the V.A.C.® dressing is also a key factor to the results obtained using this therapeutic healing regimen. The quality of life of patients with this therapy, particularly with the ambulatory V.A.C.® Freedom system is also being lauded and should play an increasingly important role in transferring the clinical benefits of treating wounds in patients in hospital to the community thus reducing overall cost. A recent Position Document on Topical Negative Pressure in Wound Management has been published by the European Wound Management Association.

The aim of this symposium at the Tenth Anniversary European Pressure Ulcer Open Meeting is to review the extensive experience with the V.A.C.® not only emphasizing the clinical evidence, cost effectiveness, but also the holistic approach to both prevention through pressure relief with the TheraKair®Visio low air loss pressure relief mattress.

Over the last eleven years a wealth of clinical and basic research has been devoted to the mechanism of how the physical forces from the V.A.C.® (reverse tissue expansion) act as transducers in stimulating different aspects of the healing cascade. The clinical success of this therapy, based on the successful outcomes achieved by clinicians throughout the world has led to the acceptance and use of this form of therapy.

However, just as important as the clinical experience are the numerous evidence-based studies that have resulted from clinical trials with negative pressure wound therapy, particularly that recently published by Armstrong and Lavery in the Lancet The quality of life of patients with this therapy, particularly the ambulatory V.A.C. Freedom system is also enhanced.

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References

1. Armstrong DG, Lavery LA: Lancet 2005;366:1704-10
2. Braakenburg A et al: Plastic & Reconstructive Surgery 2006; 118: 390-7
3. Eginton NT et al: Annals of Vasc Surg 2003;17, 645-9
4. Ford CN et al: Annals of Plastic Surgery 2002;49:55-61
5. Jeschke MG et al: Plastic & Reconstructive Surgery 2004; 113:525-530
6. Joseph E et al Wounds 2000; 12: 60-7
7. McCallon SK et al; Ostomy Wound Manag 2000, 46: 28-34
8. Moisidis E et al Plastic & Reconstructive Surgery 2004, 114: 917-22
9. Moues CM et al Wound Rep Reg 2004, 12: 11-17
10. Sheehan P et al Diabetes Care 2003, 26: 1879-82
11. Vuersstaek JD et al Journal of Vascular Surgery 2006, 44; 1029-37
12. Wanner MB et al Scand J Plast Reconstr Surg Hand Surg 2003, 37 28-33
13. European Wound Management Association (EWMA) Position Document, Topical Negative Pressure in Wound Management, London MEP Ltd 2007

Science and Clinical Evidence
Mechanisms of action of VAC Therapy and corresponding clinical benefits

Raymund E. Horch MD

Department of Plastic and Hand Surgery,
University of Erlangen Medical Center, Germany
(Director: Prof.Dr.Raymund E. Horch)

This presentation summarises recent research into the mechanisms believed to account for the efficacy of VAC Therapy, which include promoting a moist wound environment, creating mechanical forces that stimulate a biological response, promoting perfusion, reducing oedema, altering wound fluid composition and assisting in granulation tissue formation. From these underpinnings, high quality clinical trials are outlined, which translate into clinical benefit for patients. These benefits include reduction of wound volume/size, more rapid wound bed preparation, faster wound healing, enhancement of rate of graft take, decreased drainage time for acute wounds, reduction of complications, enhancement of response to first line treatment, increased patient survival and reduction of cost.

Pre-treatment of Pressure Ulcers with Topical Negative Pressure Enhances Plastic Surgical Coverage

Raymund E. Horch MD, Justus Beier, MD, Ulrich Kneser, MD, Alexander D. Bach

Department of Plastic and Hand Surgery,
University of Erlangen Medical Center, Germany
(Director: Prof.Dr.Raymund E. Horch)

Introduction

Besides the development of a considerable progress in conservative and operative treatment options the ultimate and durable coverage of pressure ulcers poses a not completely solved clinical problem. The bacterial burden of longstanding ulcers are one obstacle to one staged procedures. Optimizing the recipient wound site is a prerequisite for a successful plastic surgical flap cover. The combined approach wit hradical surgical debridment and preliminary topical negative pressure therapy (TNP) with the VAC device has been emerging as a promising tool to achieve safe and definitive surgical closure with flaps.

Methods

Since pressure ulcers are analogous to an iceberg (it has a small visible surface with a more extensive unknown base), those more advanced ulcers presenting with fat and muscle involvement and exposed bone were defined to receive surgical debridement and plastic surgical closure. Affected bony tissue was surgically removed. In our experience surgical reconstruction is attempted after radical surgical debridement followed by continuous Vacuum therapy (V.A.C.®, KCI Int., Amsterdam) until the wound bed is ready for flap surgery. Negative pressure is applied with -125 mmHG and the wound effluent is collected in a cannister. Local fasciocutaneous or myocutaneous flaps are raised and placed in the defect. The choice of flaps follows an escalation scheme to allow for secondary surgery of relapses in the future (direct closure, skin grafts, fasciocutaneous-, muscle- up to free flaps). Closed suction drainage and perioperative antibiotics administration as well as pressure relieving positoning in air Kinair fluidized beds for 3 weeks and 3 more weeks on a alternating pressure mattress is generally performed. patient may need to be placed on a bed that redistributes weight, such as one using a forced-air system

Results

Between 1983 and 2007 a total of 107 patients with single or multiple pressure ulcers were treated with flaps. From 2001 we used the vacuum device in 32 pressure ulcer patients to prepare the wound bed after surgical debridement before a fasciocutaneous or myocutaneous pedicled flap was transposed. We found that the time of wound bed preparation was significantly shortened after the introduction of VAC pre-treatment. The majority of patients (96,3%) with stage III and IV ulcers achieved sufficient wound closure within six weeks of debridement and continuous vacuum pretreatment. Secondary healing occurred in four patients (3,7%), whereas in the historic group without VAC pretreatment the former rate was 7,9%. (One of the patients with partially secondary wound healing was irradiated in the flap area.)

Discussion

Although the exact mechanism of TNP remains to be unknown, from our data it is demonstrated that clinical ooutcome is optimized when compared to non treated groups. We hypothesize TNP reduces the bacterial burden from longstanding ulcers and removes excess interstitial fluid, This in turn reduces edema and increases the vascularity of such wounds. In addition it creates a contactile force to draw the edges of the wound closer together. Typical well known complications of surgical decubital ulcer flap reconstruction include seroma, hematoma, infection, flap necrosis, wound separation, flap dehiscence. TNP pretreatment with radical surgical debridement before definitive wound closure with flaps results in a higher flap survival rate (96,3%) and fewer immediate infectious complications. We have yet to analyze thoroughly the long-term results of our reconstructed complex pressure ulcer wounds numerically, but from the preliminary data we expect this analysis to define the long-term efficacy of these reconstructions.

Integrated Therapy Systems for Better Wound Care: The science and practice of pressure ulcer management.
The Management of a patient undergoing VAC Therapy

Kathryn Vowden

Nurse Consultant Bradford Teaching Hospitals
NHS Foundation Trust and the University of Bradford

Over the last five years Vacuum Assisted Closure (VAC)® therapy has become an increasingly important part of the management strategy for patients with a variety of chronic wounds and we have learnt how to integrate the use of topical negative pressure (TNP) therapy into an individual patient's management plan.

The process starts with a detailed assessment in which the therapeutic goals are defined. Patient involvement, staff competence and regular review ensure the appropriateness and effectiveness of VAC® therapy. Care of complex wounds requires an integrated approach, involving the co-ordination of a multidisciplinary team.

We now have evidence of cost and clinical effectiveness and a robust and integrated approach that includes hospital and community teams. An education and competency programme underpins the local use of TNP therapy.

For many of the complex chronic wounds the process of care starts with debridement and once necrotic tissue has been removed VAC® therapy should be considered as one of the potential first line treatments, either to downgrade the wound, to allow consideration of surgical options or as part of an integrated process of wound management to improve the patients quality of life by achieving symptom control. VAC® therapy frequently succeeds in complex or difficult situations when other treatments have failed and the reduction in dressing frequency often reduces patient distress and pain. Exudate control is however not the only benefit, VAC® therapy also stabilises the wound margins and reduces the wound size.

Studies by Baharestani et al (2007) support this approach finding that the early use of VAC® therapy in Stage 3 and 4 pressure ulcers reduced both the duration of VAC® therapy and overall treatment time. Vac therapy has proven to be especially effective if integrated into the management of diabetic foot wounds (Armstrong & Lavery 2005). We aim to commence VAC® therapy within 24 hours of debridement for both pressure ulcers.

This presentation will illustrate by a series of cases how TNP has been integrated into wound bed preparation and chronic wound management and will explore a number of dressing techniques that can make VAC® therapy more successful from both staff and patient's perspective.

References

1. Armstrong, D. G. & Lavery, L. A. (2005) Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trial. Lancet, 366, 1704-10.
2. Baharestani, Keith, Barnes NPUAP Annual Conference February 5-9th 2007 San Antonio, TX