Surgical Palliative Care of Advanced Wounds

Review of the Current Management of Pressure Ulcers

Significance: The incidence of pressure ulcers is increasing due to our aging population and the increase in the elderly living with disability. Learning how to manage pressure ulcers appropriately is increasingly important for all professionals in wound care. Recent Advances: Many new dressings and treatment modalities have been developed over the recent years and the goal of this review is to highlight their benefits and drawbacks to help providers choose their tools appropriately. Critical Issues: Despite an increased number of therapies available on the market, none has demonstrated any clear benefit over the others and pressure ulcer treatment remains frustrating and time-consuming. Future Directions: Additional research is needed to develop products more effective in prevention and treatment of pressure ulcers.

Providing palliative care to seriously ill patients with nonhealing wounds

Patients may experience wounds at or near the end of life that are difficult to treat and may not be amenable to healing. In these cases, hospice and palliative care may be considered. Palliative care approaches include stabilization of existing wounds, prevention of new wounds, and symptom management with a focus on quality of life. Treatment goals for nonhealing wounds at the end of life include managing exudate, controlling odor, maximizing mobility and function, preventing infection, and controlling pain and other symptoms. Complementary components of palliative care are also instituted including communication and psychosocial support for patients and families.

Push-pull theory: using mechanotransduction to achieve tissue perfusion and wound healing in complex cases

Wound healing has evolved from gauze therapy to the use of proteomics, gene therapy, and cellular-based therapies in the short time span of 45 years. Education for health care providers has not kept pace with the logarithmic acceleration in technology development and treatment options. A patient with a non-healing wound requires a comprehensive work-up, including a focus on six primary points of interest. These points include the status of tissue perfusion, role of bacterial contamination, pressure applied to the tissue, the immune status of the host, co-morbid medical conditions including the patient's psychosocial status, and lastly, the status of the wound itself. Even after re-establishing macrovascular flow, many wounds either fail to improve or paradoxically worsen. Potential mechanisms for these unexpected findings include reperfusion injury, no-reflow, and the presence of stunned/hibernating tissue. Using the concept of mechanotransduction, the clinician can simulate normal pulsatile blood flow and re-establish adequate microvascular perfusion. Treatment regimens may include negative pressure therapy, electrical stimulation, ultrasound therapy, and other energy-based modalities.