Pressure Ulcer or Decubitus : clinical and etiological aspects

Pressure ulcers (PU), also called bedsores or decubitus, present a significant problem in healthcare. This thesis addresses some aspects of the aetiology of PU. The possible benefit of interventions with nutrional supplementation and the use of a risk assessment tool are evaluated. The role of reactive oxygen species in the pathogenesis of pressure ulcer coupled with possible therapeutical interventions with antioxidant drugs, is the main topic of this thesis. Chapter 2 describes the results of a clinical-pathological study of skin samples in patients with incontinence and moisture lesions. Based on the results it can be concluded that the influence of urine is not sufficient to cause skin loss. Shearing forces are an essential etiologic factor in moisture lesions. The guidelines on prevention and treatment of skin lesions in incontinent patients should be based on three main interventions: managing the incontinence problem, adequate skin care and diminishing tissue loading. In chapter 3 we evaluated the sensitivity of a risk assessment tool. It was not possible to identify patients at risk for PU solely on the basis of the use of a risk assessment tool. Identification of a patient at risk, should be based on the combination of 1) a pressure ulcer risk assessment tool 2) the clinical judgement 3) the prognosis of the underlying disease 4) the discomfort of the patient 5) inspection and palpation of the threatened area. In chapter 4 we studied the effect of nutritional supplementation on the prevention of the development of PU. Patients received after the surgical procedure a high-protein supplementation, enriched with antioxidants or placebo supplement. We found no significant positive effect of drink foods. Before advocating the use of extra nutrional supplements in PU prevention, further research is required. This does not imply that no attention has to be given to the nutritional state of the patient. However, intervention with drink foods especially can interfere with the normal daily intake, are expensive and do not integrate physical care with measures to improve quality of life. In chapter 5 we studied the effects of pressure in an animal model. After the application of pressure we investigated the damage in muscle, subcutis and cutis. Our studies showed that reperfusion injury plays an important role in the pathophysiology of PU. We have also shown that it is possible to reduce the extent of the tissue damage in PU by means of antioxidants in an animal model. In chapter 6A we present the findings of a systematic survey of the literature about the effects of topical application of dimethyl sulfoxide (DMSO) on the skin as an anti-inflammatory agent. Chapter 6B describes the results of a randomised double-blinded study, performed to assess the effects of massage with or without DMSO cream. We demonstrated a detrimental effect on the occurrence of PU on the heels in humans with a locally applied antioxidant. More animal and human studies are required to establish the safety and effectiveness of antioxidantal therapy