SOME ASPECTS OF SECONDARY PREVENTION OF THE FORMATION AND PROGRESSION OF DECUBITAL PURULOUS NECROTIC PROCESSES (BEDSORES) AND CLINICAL STRATEGIES OF COMPLEX TREATMENT

Abstract

To determine the risk of formation of decubitus ulcers, attempts to quantify the compression effect of external factors are effective. Treatment of bedsores, despite the use of known methods and techniques, is often expensive and ineffective. Adequate care and treatment of patients with chronic wounds and, in particular, bedsore purulent- necrotic complications are possible only with the use of complex algorithms. The main factor in successful prevention is the prevention of compression of the skin and subcutaneous fat, which is achieved by changing the position of patients in bed, excluding night time. According to the European expert group, the necessary frequency of repositioning the patient depends on the surface on which the patient is. Alternative methods aimed at reducing the pressure force are special plastic splints, anti-bedsore mattresses, beds, pillows, pads, as well as mattresses filled with water, air, foam, gel or a combination thereof. In 2009, the European pressure ulcer advisory group created and implemented a modern clinical classification. First, dystrophic, and then ulcerative- necrotic changes of the skin (bedsores of the I and II stages), the subcutaneous base, sometimes with damage to the skeletal muscles and periosteum (DU III and IV stages), may develop contact perichondritis, chondritis or (and) periostitis, osteomyelitis. The purpose of our work was to investigate, based on data from the literature and clinical experience, the possibilities of prevention and to optimize the complex treatment of chronic compressive purulent-necrotic processes (bedsores), in particular decubitus ulcers of the III–IV stages in the palliative care department, taking into account the author’s modification of the classification of local lesions and clinical strategies. Based on 10 years of experience in secondary prevention and treatment of bedsores in 873 patients, we proposed the author’s optimized clinical classification and formulated predictors of the risk of complications requiring repeated revisions, necrotectomies, and sequestrnecrectomies. Adequate surgical remediation was performed in all cases of colliquative necrosis and suppuration. The DOMINATE strategy, which can be considered a clinical protocol in surgical clinics, includes the removal of non-viable tissues from the wound in the presence of colliquative (wet) necrosis or limited (demarcated) islands of dry necrosis. Iatrogenically, during necrotomy, cells in a state of necro- and parabiosis are also removed, the number of bacteria and the intensity of their growth decrease. On the basis of the DOMINATE strategy for palliative care departments, we have created the NODITE strategy, pathogenetically based and adapted for non-specialized departments, with adequate implementation of the principles of care and therapy, which also includes the opening and drainage of purulent sinuses with precise staged necrectomy. In case of impossibility of one-moment removal of necrotic masses from the positions of Damage-control according to the general condition of the patient or additional/reformation of necroses, the tactics of repeated, programmed rennecrectomies were used.The correct choice of absorbent bandages allows you to control the exudation process, prevent the disintegration of new collagen structures and influence neovascularization in the proliferative phase. It is claimed that the use of decompression orthopedic mattresses, circles and techniques to reduce “chronic” constant pressure on affected tissues provides a positive clinical effect, halving the probability of progression of necrobiosis, compared to patients who do not use some means of decompression.