ORIGINAL ARTICLE Regional anaesthesia with sedation protocol to safely debride sacral pressure ulcers Daniel K O’Neill, Bryan Robins, Elizabeth A Ayello, Germaine Cuff, Patrick Linton, Harold Brem O’Neill DK, Robins B, Ayello EA, Cuff G, Linton P, Brem H. Regional anaesthesia with sedation protocol to safely debride sacral pressure ulcers. Int Wound J 2012; 9:525–543 ABSTRACT A treatment challenge for patients with sacral pressure ulcers is balancing the need for adequate surgical debridement with appropriate anaesthesia management. We are functioning under the hypothesis that regional anaesthesia has advantages over general anaesthesia. We describe our regional anaesthesia protocol for perioperative and postoperative management. Key words: Anaesthesia • Pressure ulcer • Regional • Sacral • Wound INTRODUCTION bone (2). These wounds may go unnoticed for Key Points A pressure ulcer can be defined as a ’localised extended periods of time because they are more injury to the skin or underlying tissue, usu- prevalent in bed bound, paralysed patients as • more than 90% of the pressure ally over a bony prominence that results well as patients older than 65 years (2). The ulcer diagnoses were a sec- ondary diagnosis relating from from pressure, including pressure associated annual occurrence of these pressure ulcers is · another principal problem with shear’ (1). These ulcers can be exten- approximately 1 3–3 million (3), including over • it is vital that these ulcers are sive with damage to the skin and under- 500 000 hospitalisations where pressure ulcers properly diagnosed and treated lying soft tissue, muscle and even exposing were diagnosed (4). Nearly three out of four extended stays were in people over 65 years of age (4), and this age group also accounted for Authors: DK O’Neill, MD, Department of Anesthesiology, New 56·5% of principal diagnoses as well. More than York University School of Medicine, New York, NY 10016, USA; 90% of the pressure ulcer diagnoses were a sec- B Robins, BS, NYU-NIH Summer Program, New York University ondary diagnosis relating from another princi- Langone Medical Center, New York, NY 10016, USA; EA Ayello, · PhD, RN, ACNS-BC, CWON, MAPWCA, FAAN, Faculty, Excelsior pal problem (4), costing hospitals $10 2 billion College School of Nursing, The John A. Hartford Institute of in addition to the $752 million caused by pri- Geriatric Nursing, New York University College of Nursing, mary pressure ulcers (4). Pressure ulcers cause New York, NY, USA; G Cuff, BSN, MPH, CCRP, Department of longer hospital stays (4) and increase the risk Anesthesiology, New York University Langone Medical Center, of infection on top of the treatment costs out- New York, NY 10016, USA; P Linton, MD, Department of Anesthesiology, New York University School of Medicine, New lined above (5). There is substantial evidence York, NY 10016, USA; H Brem, MD, Division of Wound Healing that supports the fact that pressure ulcers are and Regenerative Medicine, Department of Surgery, Winthrop also associated with increased mortality and University Hospital, Mineola, NY, USA morbidity rates (6) and are the cause of death Address for correspondence: DK O’Neill, MD, Department of Anesthesiology, New York University School of Medicine, New in more than 104 000 persons per year in the York, NY 10016, USA USA alone (7). Therefore, it is vital that these E-mail: [email protected] ulcers are properly diagnosed and treated. © 2012 The Authors International Wound Journal © 2012 Blackwell Publishing Ltd and Medicalhelplines.com Inc 525 Regional anaesthesia with sedation protocol Key Point Challenges in healing sacral pressure the surgical debridement then finding the most ulcers effective mixture of topical, subcutaneous and • the vital aspect in the pain Pressure ulcers in adults usually occur over systemic anaesthesia (22). management and treatment of bony prominences such as the sacrum or the chronic wounds is first making heel (8,9). The sacrum located in the lower the decision to perform the sur- The role of surgery in treating sacral gical debridement then finding dorsum is the most common site for pressure pressure ulcers the most effective mixture of ulcers, where approximately 32% of pressure Surgery has inherent risks. Many patients, fam- topical, subcutaneous and sys- ulcers occur according to one study (10). Of ily members and attending physicians believe temic anaesthesia the newest category of pressure ulcers as that taking patients to the operating room for defined by the National Pressure Ulcer Advi- surgery and anaesthesia is excessively risky sory Panel (NPUAP) (1), suspected deep tissue compared with medical therapy. The wound injury is surprisingly more commonly found patient has more comorbidities and is at greater on the heels (41%) rather than on the sacrum risk than a normal average patient as evident (19%) (11). Once these ulcers are formed, they by the fact that wound patients have an aver- may become chronic wounds with physiologi- age score of 3·09 on the American Society of cal impairments that prevent the stimulation of Anaesthesiologists (ASA) physical status clas- wound healing even further (12-14). The blood sification scale (Table 1) compared with the supply to the sacral region defines an angio- overall average of 2·03 value for anaesthesia some. Compromised blood supply from pres- patients at a major university hospital (23). The sure, hypothermia and vasopressors can both ASA score does increase with severity of dis- contribute to the development of sacral pres- ease and the impact on function. The ordinal sure ulcers, as well as impair the angiogenic scale is based on an assessment of the entire response during wound healing. Sharp surgical present health condition of the patient dur- debridement promotes wound bed preparation ing the preoperative evaluation. The number for closure. The angiogenic response is depen- of comorbidities does combine to increase the dent upon where the region is anatomically and score, but it is not linear. For example, a single that the response is significantly skewed away disease with end-organ damage (like end-stage from the lower dorsum (15,16). This decreased renal disease requiring dialysis), which impairs angiogenic response contributes to the slower function places a patient at higher periopera- healing in the lumbosacral area (17), which tive risk than six relatively benign problems increases the likelihood of the need for sur- such as a lipoma or pin worms. gical intervention in a sacral pressure ulcer. The incidence of complications and mor- A sacral pressure ulcer is in close proxim- tality for patients who undergo anaesthe- ity to the rectum, which increases the likeli- sia is greater among patients with a higher hood of fecal contamination from incontinence ASA score (24). However, sharp surgical and can hinder healing in addition to mak- ing the wound larger (18,19). According to a Table 1 American Society of Anaesthesiologists physical protocol for the comprehensive treatment of status classification pressure ulcers (2), these aspects make sacral pressure ulcers a prime candidate for operative Class Patient Status debridement to allow tissue regeneration to I Healthy patient with no comorbidities start (20,21). Sharp debridement using a scalpel II A patient with mild systemic disease that should not is the preferred method used to eliminate the affect anaesthesia and surgery necrotic tissue, which hinders the healing pro- III A patient with a severe systemic disease that requires cess and possibly masks other factors such special care during surgery as infection that impede wound closure as IV A patient with a severe systemic disease or end-organ well (2). The National Pressure Ulcer Advi- damage that is life threatening and which must be sory Panel (NPUAP)/ European Pressure Ulcer addressed preoperatively, intraoperatively and Advisory Panel (EPUAP) Clinical Guidelines postoperatively by the anaesthesia team V A moribund patient whose life expectancy does not recommends that the vascular status and sta- exceed 24 hours irrespective of surgery bility of eschar heel ulcers be determined prior to sharp debridement (1). The vital aspect in Adapted from American Society of Anaesthesiologists. ASA the pain management and treatment of chronic physical status classification system. Available at: http://www.asahq. wounds is first making the decision to perform org/clinical/physicalstatus.htm © 2012 The Authors 526 International Wound Journal © 2012 Blackwell Publishing Ltd and Medicalhelplines.com Inc Regional anaesthesia with sedation protocol debridement is necessary to remove sources 5-6% of total hospitalisation costs (28,29). These Key Points of infection and sepsis from the wound that costs result from expensive intraoperative pro- will increase mortality rates or prevent wound cedures, medications, staffing and physiologi- • sharp surgical debridement is closure (10). This procedure has been described cal monitors, which places them at the forefront necessary to remove sources of in detail and has been shown to be safe and of intense health care industry scrutiny (30). infection and sepsis from the wound that will increase mor- have low-mortality rates even in patients with One method to cut costs to both anaesthesia tality rates or prevent wound multiplecomorbidities (10). departments and hospitals would be to closure The formation of new pressure ulcers is also decrease Postanaesthesia Care Unit (PACU) • the operating room provides something to consider when evaluating