Cath Lab Digest

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Index: Ostomy Wound Manage. 2008;54(10):42-57.

Abstract

  Heels are the second most common anatomical location for pressure ulcers. A combination of risk factors, including pressure, may cause ulceration. Heel pressure ulcers are a particular concern for surgical patients. A review of the literature, including poster presentations, shows that controlled clinical studies to assess the effectiveness and cost-effectiveness of available interventions are not available. Case series (with or without historical controls) as well as pressure ulcer guideline recommendations suggest the most important aspect of heel ulcer prevention is pressure relief (offloading). It also has been documented that the incidence of heel ulcers can be reduced using a total-patient care approach and heel offloading devices. Guidelines, observational studies, and expert opinion intimate that reducing heel ulceration rates can be expected to improve patient outcomes, decrease costs associated with their care, and avoid costs related to hospital-acquired pressure ulcers. The heel pressure ulcer prevention strategies reviewed should be implemented until the results of prospective, randomized controlled studies to compare the effectiveness and cost-effectiveness of these strategies are available.

KEYWORDS: heel pressure ulcer, perioperative pressure ulcer, heel protector device, heel offloading device

     A pressure ulcer is a localized injury to the skin and/or underlying tissue that usually develops over a bony prominence as a result of pressure or pressure with shear or friction forces.¹ Heel ulcers are the most common facility-acquired pressure ulcer in long-term acute care facilities² and the second most common pressure ulcer overall.³ Heel ulcers can be physically debilitating and painful and can lead to serious complications such as infection, cellulitis, osteomyelitis, septicemia, limb amputation, or death, and can increase healthcare and litigation costs. However, with appropriate evidence-based prevention, most heel pressure ulcers can be avoided.⁴ To summarize pertinent information on the clinical, emotional, and financial significance of heel pressure ulcers, selected literature and poster presentations are reviewed and wound care clinicians’ insights on the challenges of heel pressure ulcers are provided.

Anatomy/Physiology/Pathophysiology of the Heel Pressure Ulcer

     Pressure ulcers are ultimately a result of tissue damage due to inadequate tissue perfusion.⁵ Direct sustained pressure, repetitive moderate pressure, shear forces, and reperfusion injury all contribute to tissue ischemia and thrombotic occlusion of the capillary vasculature.⁶

     Tissue compromised by maceration, friction injury, or dryness is particularly vulnerable.⁷ Bacterial colonization of existing ulcers, altered cellular responses, and systemic stress also may contribute to tissue injury.⁸

     According to a model proposed by Mustoe et al,⁸ reperfusion injury is an exacerbation of tissue injury that results as blood returns to the tissue and white blood cells accumulate in and around the damaged small capillaries. The accumulation of damaged cell byproducts and white blood cells obstructs the capillaries, aggravating ischemia and local inflammatory response. Free radicals produced in the cells during ischemia are released when blood flow is restored. These free radicals damage cellular proteins, DNA, and cell membranes, contributing to cell death. Thus, tissues damaged by pressure-induced ischemia are further damaged as the tissue is reperfused.