Deep Tissue Pressure Injuries: Advances in Understanding and Prevention

Abstract

Deep tissue pressure injuries (DTPIs) represent a significant challenge in healthcare, particularly in populations at high risk of immobility-related complications. Unlike superficial pressure injuries, DTPIs originate in the deeper layers of tissue, often near bony prominences, and can progress rapidly if not identified and managed effectively. This article delves into the etiology, pathophysiology, and prevention strategies of DTPIs, leveraging insights from current research, including contributions from the European Pressure Ulcer Advisory Panel (EPUAP) and other key sources.

Introduction

Pressure injuries, commonly referred to as bedsores or decubitus ulcers, are localized damage to the skin and underlying tissues, often resulting from prolonged pressure or shear forces. Among these, DTPIs are particularly insidious because they develop beneath intact skin, making early detection difficult (EPUAP et al., 2019). DTPIs account for a significant proportion of pressure injuries, particularly in patients in intensive care units (ICUs), nursing homes, and those undergoing prolonged surgical procedures (Gefen et al., 2020).

This article aims to provide a comprehensive overview of the mechanisms, risk factors, and management strategies for DTPIs, supported by evidence-based research and guidelines.

Pathophysiology of Deep Tissue Pressure Injuries

DTPIs are caused by sustained mechanical loading that exceeds the tissue’s tolerance for pressure, shear, or both. The damage originates in the muscle and fascia layers, close to bony prominences, and progresses outward toward the skin (Gefen, 2018). Key factors contributing to tissue damage include:

1. Ischemia: Prolonged pressure impairs blood flow, leading to oxygen and nutrient deprivation in the tissues.
2. Reperfusion Injury: Reintroduction of blood flow after ischemia can result in oxidative damage, exacerbating tissue necrosis (Wounds International, 2020).
3. Deformation-Induced Cell Death: Direct mechanical deformation of cells, particularly in muscles, can lead to necrosis, even in the absence of ischemia (Ceelen et al., 2018).
4. Inflammation: Sustained pressure triggers a cascade of inflammatory responses, which can amplify tissue damage and delay healing (EPUAP et al., 2019).

The unique pathophysiology of DTPIs underscores the importance of early detection and prevention strategies tailored to mitigating deep tissue damage.

Risk Factors

Risk factors for DTPIs overlap with those for general pressure injuries but are distinct due to the deeper tissue involvement. Key factors include:

1. Patient-Related Factors:
   • Immobility, such as in patients with spinal cord injuries or prolonged ICU stays (vanGilder et al., 2020).
   • Poor nutritional status, particularly low albumin levels, which reduce tissue resilience (Coleman et al., 2014).
   • Comorbidities, including diabetes mellitus and peripheral vascular disease, which impair tissue perfusion and healing capacity (EPUAP et al., 2019).
2. Extrinsic Factors:
   • Shear forces from sliding or repositioning patients.
   • Sustained pressure, especially over bony prominences like the sacrum and heels (Gefen, 2018).
   • Microclimate, including increased skin moisture and temperature, which can exacerbate tissue breakdown (Wounds International, 2020).
3. Device-Related Factors: Medical devices, such as catheters or braces, can exert localized pressure, increasing the risk of DTPIs (Black et al., 2018).

Prevention Strategies

Prevention is paramount in reducing the burden of DTPIs, with interventions focusing on pressure redistribution, early detection, and patient-specific risk management.

1. Pressure Redistribution Devices

Specialized support surfaces, including alternating pressure mattresses and more advanced methods like lateral turning systems , have demonstrated efficacy in reducing tissue loading and preventing pressure injuries (EPUAP et al., 2019). These devices distribute pressure more evenly and reduce shear forces, particularly in high-risk patients. ABeWER’s multiTURN® 6, when combined with comprehensive scientific monitoring, provides an optimal method for effectively addressing deep tissue pressure injuries.

2. Repositioning Protocols

Frequent repositioning of patients is a cornerstone of prevention. The EPUAP and National Pressure Injury Advisory Panel (NPIAP) recommend repositioning patients at least every two hours to alleviate pressure on vulnerable areas (EPUAP et al., 2019). Repositioning should be complemented with techniques to minimize shear and friction.

3. Early Detection Technologies

Emerging technologies, such as sub-epidermal moisture (SEM) sensors, allow for non-invasive monitoring of tissue health, facilitating early detection of DTPIs before they become clinically apparent (Moore et al., 2018).

4. Education and Training

Education of healthcare providers and caregivers is critical in ensuring adherence to prevention protocols. Training should emphasize the importance of risk assessment, proper positioning, and the use of support surfaces (Coleman et al., 2014).

5. Nutritional Interventions

Nutritional support, particularly ensuring adequate protein and micronutrient intake, can enhance tissue resilience and promote healing in at-risk patients (Lechner et al., 2020).

Management of Established DTPIs

While prevention is the primary focus, effective management of established DTPIs is essential to prevent complications and promote healing.

1. Debridement and Wound Care

Management involves debridement of necrotic tissue, wound cleansing, and the use of advanced dressings, such as foam or hydrocolloid dressings, to maintain a moist wound environment (Wounds International, 2020).

2. Adjunctive Therapies in ulcers

Adjunctive therapies, including negative pressure wound therapy (NPWT) and hyperbaric oxygen therapy, may be beneficial in selected cases (EPUAP et al., 2019).

3. Multidisciplinary Approach

Effective management requires collaboration among healthcare professionals, including physicians, nurses, dietitians, and physiotherapists, to address all aspects of patient care (Gefen, 2020).

Future Directions and Research Gaps

Despite advancements in prevention and management, significant gaps remain in understanding DTPIs. Future research should focus on:

1. Biomarkers for Early Detection: Identifying biomarkers associated with tissue damage could enable earlier intervention (Moore et al., 2018).
2. Personalized Prevention Strategies: Tailoring interventions based on individual patient risk profiles could improve outcomes.
3. Longitudinal Studies: Long-term studies are needed to evaluate the effectiveness of prevention strategies and devices (EPUAP et al., 2019).

Conclusion

DTPIs are a complex and costly healthcare challenge, but advancements in technology, education, and multidisciplinary care offer promising avenues for prevention and management. Collaborative efforts among researchers, clinicians, and manufacturers, such as ABeWER’s contributions to innovative support surfaces, are essential in reducing the global burden of DTPIs.

References

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