Operative debridement of pressure ulcers

Abstract

Background: Infection in severe pressure ulcers can lead to sepsis with a 6-month mortality as high as 68%.

Methods: Operative records of 142 consecutive operative debridements on 60 patients in a dedicated wound healing inpatient unit were reviewed, from the Wound Electronic Medical Record, for identification of key steps in debridement technique, mortality, unexpected returns, and time to discharge following debridement.

Results: The mean age of the patients was 73.1 years, and 45% were men. Most wounds (53%) were located on the hip (ischial or trochanteric); others were on the sacrum (32%) and the heels (14%). The mean initial wound area prior to debridement was 14.0 cm(2), and 83% of debridements were performed on stage IV pressure ulcers. The postoperative hospital stay averaged 4.1 days. Key steps in the technique included (1) exposure of areas of undermining by excising overlying tissue; (2) removal of callus from wound edges; (3) removal of all grossly infected tissue; and (4) obtaining a biopsy of the deep tissue after debridement of all nonviable or infected tissue for culture and pathology to determine the presence of infection, fibrosis, and granulation tissue. There was one death 9 days post-debridement of a sacral ulcer and one unplanned return to the operating room for bleeding 8 days post-debridement.

Conclusions: Operative debridement of pressure ulcers is safe, despite the medical co-morbidities in patients with severe pressure ulcers. Proper debridement technique may prevent sepsis and death in patients with multiple co-morbid conditions.

Fig. 1

Exploration of the wound for undermining can be performed with a gloved finger or a sterile cotton swab, as depicted here

Fig. 2

Outline of triangular segment of undermining

Fig. 3

Triangular segment of skin covering undermining removed

Fig. 4

Triangular segment of skin removed and sent to pathology

Fig. 5

a Low-power view of excised skin over area of undermining. The superior black arrow indicates hyperkeratotic and thickened skin, and the inferior arrow indicates the ulcer bed. A layer of granulation tissue (G) was present as deeper fibrosis (F). b Pressure ulcer debridement often may extend and require removal of scarred muscle (M). F regions of fibrosis; G an area of granulation tissue. c A fragment of viable bone (B) as evidenced by nucleated osteocytes (black circle) and adjacent fibrosis (F)

Fig. 6

Application of Floseal to achieve hemostasis

Fig. 7

Application of collagen to achieve hemostasis