Quick Slough Removal, Pain Relief and Wound Closure for Three Extremely Debilitated Pressure Ulcer Patients

Problem:

How should the pressure ulcers of three extremely debilitated patients be managed?

· 19-yr-old male, post traumatic-head-injury.  Admitted with unstageable 4.0cmx4.0cm 40% slough-filled, 60% avascular coccyx pressure ulcer.  Previous facility tried enzymatic debridement for undisclosed time.

· 90-year-old alert diabetic female on low-air-loss bed with hypertension, arthritis, hypothyroidism, incontinence and venous insufficiency.  After 18 days of hydrogel, malodorous, erythematous 2.0cmx3.0cmx0.5cm heel ulcer was 60% clean without granulation, 40% slough.  Periwound erythema, copious yellow exudate.  Frequently refused repositioning or off-loading.  Antibiotics for cellulitis.

· 89-year-old diabetic female on O₂ for CHF, severe edema of lower extremities.  0.5cmx2.0cmx0.1cm heel pressure ulcer.  Low-air-loss bed with heels floated; repositioned every two hours.  Antibiotics for acute infections.  Wound autolytically, enzymatically debrided, then negative pressure for 8 weeks.  Discontinued due to severe pain, anemia.  10% epithelized, fully granulated. 

Rationale:

Absorbent non-adherent polymeric membrane dressings support quick wound healing and facilitate wound debridement through synergistic component actions.  They can inhibit pain continuously, often eliminating the need for systemic pain relievers. 

Methodology:

Silver bordered polymeric membrane dressings were applied, checked every shift and replaced without manual wound cleansing every 2 - 3 days or whenever 50% saturated. 

Results:

By the second weekly assessment, most of the slough had been dissolved or pulled into or onto the dressings, leaving all three wound beds 90% - 100% granulating.  The 19-year-old’s wound closed in only 6 weeks; the 90-year-old’s wound closed in 10 weeks.  The 89-year-old experienced dramatic wound pain relief, greatly reducing her pain medication use; her wound closed in 7 weeks.

Conclusion:

We routinely use enzymatic debriders to remove slough and negative pressure therapy to close pressure ulcers.  But, these three cases raise questions about the most efficacious way to accomplish these goals.  Silver polymeric membrane dressings also solved pain, infection and blood loss problems for the 89-year-old.