Current Insights On Treating Heel Pressure Ulcers
If the patient is ambulatory with good rehabilitation potential, Dr. Suzuki treats the wound aggressively. Once he has resolved the offloading issues, he performs an arterial perfusion study, a SPP and Pulse Volume Recording (PVR) test to rule out ischemia. He then aggressively debrides the wound, including the Achilles tendon or calcaneus if they appear necrotic. If the tendon or calcaneus is exposed, Dr. Suzuki uses negative pressure wound therapy (VAC therapy, KCI) to aid in the development of granulation tissue. Dr. Suzuki then applies a skin graft or skin substitute to facilitate final wound closure.
Dr. Suzuki does not believe in the concept of “auto-amputation,” which is leaving the gangrenous toes indefinitely, hoping the body will demarcate the necrotic toe and let the toe fall off. “I consider these gangrenous toes as open wounds, and I prefer swift toe/partial foot amputation to achieve wound closure, given the perfusion is adequate,” concludes Dr. Suzuki.
A: Dr. Brietstein routinely orders albumin and prealbumin levels. He empirically starts the patient on zinc sulfate 220 mg daily, vitamin C 500 mg daily and a multivitamin with minerals, and routinely calls for a nutritional consult. For these patients, Dr. Brietstein says he is “extremely conservative,” using enzymatic debriding agents, hydrocolloids and Betadine solution in the presence of eschars.
For a patient who is truly terminal and non-ambulatory, or if the patient or family opts out of aggressive wound care, Dr. Suzuki may advocate palliative wound care. His palliative regimen consists of applying Betadine to “dry out” and temporize the heel eschar. Alternately, he says one may apply a hydrogel or hydrocolloid a few times a week to debride the heel eschar in a painless autolytic manner.
“Palliative care does not mean giving up on the patient,” clarifies Dr. Suzuki. “We would still provide offloading to minimize the pain and keep the pressure ulcers from becoming worse. We would also give adequate analgesics, even if the patient would not or could not verbalize his or her wound pain.”
Dr. Fife concurs. She discusses with the patient and family what the patient’s care will entail. As she notes, palliative care is directed at pain and infection control. With these patients, Dr. Fife says the goal is not necessarily healing per se but more of a focus on comfort and a reduction in the risk of infection. She usually uses topical antimicrobials to control infection. Dr. Fife says one must take an aggressive approach toward treating pain.
Q: Do you have any other pearls on heel pressure ulcers?
A: For any heel pressure ulcer patients, Dr. Suzuki ensures the patients undergo assessment, with the help of primary care physicians and wound/ostomy/ continence nurses, for pressure ulcers in other areas of the body (shoulders, hips, buttocks, etc.). If these patients have ulcers in other areas, Dr. Suzuki says they may need prescription wheelchair cushions, mattresses and/or bed overlays.
When patients with diabetes, particularly those with peripheral neuropathy or leg ischemia, are hospitalized, Dr. Suzuki takes extra caution to monitor their heels. He has found it may only take a few days of hospitalization for these high-risk patients to develop full-thickness ulcers.
As Dr. Fife notes, the key to caring for heel pressure ulcers is knowing the patient’s vascular status. If patients have adequate vascular status, she says they are candidates for any aggressive interventions in your armamentarium. In her clinical experience, Dr. Fife has found negative pressure wound therapy effective when one uses it after the debridement of heel pressure ulcers.
If patients do not have adequate vascular status, “then all your interventions are doomed to fail,” emphasizes Dr. Fife.
“You might end up just prolonging the inevitable (an amputation), creating unrealistic expectations for the family and increasing the likelihood of the development of osteomyelitis.”