[Presentation of Case]
An 82-year-old woman presented to the emergency department (ED) with a fever for one day and drowsy consciousness for about 1 week. She had a medical history of diabetes mellitus, hypertension, lacunar infarcts with vascular dementia, Parkinsonism, spinal cord injury with neurogenic bladder dysfunction for which cystostomy was performed, osteoporosis with multiple spinal compression fractures for which she underwent an operation, and chronic hepatitis C infection. She received regular follow-up at the outpatient department (OPD) of this hospital.
She was otherwise in her usual state of health and was partially dependent in activities of daily living (ADLs) before this admission. She could walk with a walker, but decline in functional status was found in recent 6 months. About one week prior to this visit, she became drowsy, with decreased verbal output. Later, she developed a fever with general malaise. She did not have cough, diarrhea, nausea or vomiting. On arrival at the ED, the blood pressure was 170/110 mmHg, the pulse rate was 107 beats per minute, the respiration rate was 22 breaths per minute, and the temperature was 38.1℃. Physical examination showed no bruits of the bilateral carotid artery, cardiac murmur, or crackles or wheezes of the lungs. The abdomen was flat and no tenderness was detected; the bowel sound was normoactive; andno bruits was detected in the abdominal aorta. Peripheral pulses showed decreased pulse of the right popliteal and pedalartery, compared with that of the left side. Two grade 4 pressure ulcers of about 13.5 x 6 cm at the sacral area and 0.5 x 0.5 cm at the left ankle area were noted. There was yellowish discharge and redness surrounding the pressure ulcer at the left ankle. Glasgow Coma Scale was E4V2M4. Neurological examination showed that muscle power was around 3-4 in the right upper limb, 2 in the right lower limb, 4 in the left upper limb, and around 3-4 in the left lower limb. The gait was examined because the patient could not stand.
Laboratory examinations showed an elevated white cell count and pyuria. A chest radiograph showed no active lung lesion. Cefazolin was begun for urinary tract infection and pressure ulcers. The urine culture later yielded group B Streptococcus. Cefazolin was changed to ampicillin-sulbactam according to antimicrobial susceptibility test results. In addition, insulin was given for blood glucose control. Delirium was suspected from acute infection. She was then admitted to the general ward for further management.
Hemogram |
07/25 |
07/28 |
08/06 |
08/22 |
|
|
|
|
|
WBC (k/μL) |
13.18 |
9.54 |
7.26 |
4.18 |
RBC (M/μL) |
3.94 |
4.11 |
3.03 |
3.04 |
Hemoglobin (g/dL) |
11.9 |
12.1 |
9.1 |
9.1 |
HCT (%) |
35.2 |
36.8 |
27.0 |
27.4 |
MCV (fL) |
89.3 |
89.5 |
89.1 |
90.1 |
MCH (pg) |
30.2 |
29.4 |
30.0 |
29.9 |
MCHC (g/dL) |
33.8 |
32.9 |
33.7 |
33.2 |
PLT (k/μL ) |
366 |
342 |
384 |
229 |
Band (%) |
0.0 |
0.0 |
0.0 |
13.3 |
Segment (%) |
81.9 |
79.7 |
61.2 |
34.3 |
Eosinophils (%) |
0.0 |
0.1 |
1.8 |
0.0 |
Basophils (%) |
0.1 |
0.0 |
0.3 |
1.0 |
Monocyte.(%) |
7.2 |
7.0 |
9.0 |
3.8 |
Lymphocytes(%) |
10.8 |
13.2 |
27.7 |
47.6 |
Atypical lymphocytes (%) |
0.0 |
0.0 |
0.0 |
0.0 |
Biochemistry |
07/25 |
07/28 |
08/06 |
08/22 |
Alb (g/dL) |
|
|
2.4 |
2.9 |
T-BIL(mg/dL) |
|
0.59 |
|
|
AST (U/L) |
|
|
18 |
|
ALT (U/L) |
17 |
|
11 |
|
BUN (mg/dL) |
25.7 |
39.1 |
7.9 |
|
CRE (mg/dL) |
0.9 |
0.6 |
0.4 |
0.4 |
Na (mmol/L) |
135 |
132 |
134 |
139 |
K (mmol/L) |
3.1 |
3.9 |
4.3 |
3.8 |
CRP (mg/dL) |
5.14 |
3.91 |
0.16 |
|
Figure 1. Severe osteoarthritis of the left tibiotalar joint with suspected superimposed septic arthritis and early osteomyelitis at the distal tibia and talus. Subcutaneous edema or cellulitis at the left dorsum foot
Figure 2. Peripheral arterial occlusive disease with severe stenosis or occlusion of the bilateral popliteal and right fibular artery
[Course and Treatment]
After antibiotic treatment and wound care, the delirium improved gradually with an increased verbal output. Because of poor recovery of pressure ulcer at the left ankle and decrease of the left pedal pulse, diagnoses of peripheral arterial occlusive disease and osteomyelitis were made. Magnetic resonance imaging showed suspected septic arthritis of the left knee joint and early osteomyelitis at the distal tibia and talus (Fig. 1), cellulitis at the left dorsum foot and peripheral arterial occlusive disease with severe stenosis or occlusion of bilateral posterior tibial artery and the right fibular artery (Fig. 2). Ampicillin-sulbactam was changed to ceftriaxone. She underwent percutaneous occlusion balloon angioplasty 2 days later. After the procedure, the pulse intensity of the left popliteal and pedal artery increased and equaled to those of the right side. A blood test showed iron deficiency anemia and anemia of chronic inflammation. A test for fecal occult blood was negative. Iron supplement was added. The fever resolved and the white blood cell count returned to normal. Pressure ulcers improved significantly, and she was discharged with oral antibiotic treatment.
[討論]
根據美國國家壓瘡諮詢委員會(NPUAP)定義，壓瘡是「因壓力或合併剪力，而導致皮膚或皮膚下的組織局部損傷，常發生於骨突處」。當局部皮膚受到壓力，如果壓迫時間過長，妨礙微血管血液供應導致缺血、缺氧，使得組織需氧無法得到充足供給因而導致損傷，嚴重者壞死，結果就是我們臨床上所看到的壓瘡了。
壓瘡(pressure sore)常見於肢體活動不良、長期臥床、衰弱、營養不良及合併多種慢性病的老人身上。根據美國過去一項研究調查顯示，醫院裡發生壓瘡的盛行率為2~12.9%，長期照護機構為1.9%~23.9%；居家照護為0~17%。壓瘡看似局部組織損傷，但產生壓瘡後所引發後遺症，將嚴重影響生活起居，患者往往因為疼痛而不敢活動，或因本身多種共病症導致傷口復原較為困難。除了增加照護難度外，提高醫療成本，甚至因容易導致骨髓炎及敗血症等嚴重感染而致死。臨床上常見老年人身上新發生的壓瘡，常伴隨身體其他部位不等程度壓瘡出現，因此產生壓瘡的老年人，相較於沒有得到壓瘡者，第一年的死亡率可能高達60%。
老人通常會同時合併多種慢性病於一身，尤其65歲以上老年人糖尿病盛行率約為20%，若加上失智、衰弱、肢體退化等因素造成老人長期臥床，將大幅增加壓瘡產生的機會。一旦產生壓瘡，合併糖尿病、腎臟、肝臟疾病、周邊血管疾病、長期類固醇使用、癌症體質等因素影響下，再加上不適當的照護品質，不僅延緩傷口癒合時間，更增加感染機會，嚴重者將導致死亡。
臨床上，壓瘡風險評估量表就是一種有效評估壓瘡風險的篩檢工具，藉由預先發現壓瘡的危險因子，實施預防性照護措施，以防止其發展、惡化及產生併發症。Braden及Norton量表在各種不同的評估量表中，其敏感度及特異性是最均衡的。尤其是Braden量表，是目前最被廣泛使用的壓瘡風險預測篩檢表(表一)。一般而言，如果老年人的Braden scale score總分≦18，並同時有下列合併症，項目越多，得到壓瘡的機會也越大(表二)。
在老年人壓瘡常見的部位中，發現有足跟壓瘡(Heel pressure ulcer)，必須要更加小心注意形成傷口其背後的原因。足跟因為跟骨(Calcaneus)與皮膚間幾乎沒有皮下脂肪組織作為緩衝，且相對於其他部位較為突出，導致跟骨單位面積壓力較大，因此容易形成壓瘡。老年人產生下肢(包括足跟、足踝、腳趾)壓瘡的比率，在某些行動不良的病人身上，甚至超越背部發生的機會。根據國外研究顯示，因手術而躺床的病人，在術後7天內得到跟骨壓瘡的機會達3.5%。因此如何防患於未然，事先減少病人得到壓瘡的機會，往往比發生壓瘡後再積極的治療還要來得重要。
Okuwa等人在2009年的研究中，歸納出3種容易得到足跟壓瘡的危險因子: (1)低ABI值 (ankle brachial index) (2)較長的臥床時間(3)男性。其中ABI值如果小於0.8 (cut-off value)，跟骨發生壓瘡的機會將大幅增加。所謂ABI就是測量背動脈(dorsalis pedis artery) 與脛後 (posterior tibial artery) 動脈收縮壓與肱動脈(brachial artery) 的比值。一般ABI正常值介於0.9~1.3。若ABI介於0.4~0.9，則要懷疑動脈可能有輕度至中度阻塞。若ABI小於0.4，動脈可能已經有嚴重阻塞。大於1.4，則要考慮動脈內側管壁鈣化，導致動脈彈性不佳。臨床若懷疑有周邊動脈疾病(PAOD, peripheral arterial occlusive disease)，除了前述測量ABI外，非侵入式檢查血管超音波(vascular doppler flow study)、電腦斷層 (computed tomography)及核磁共振檢查 (magnetic resonance image [MRI] with angiography)都是有效的檢查方式。核磁共振檢查除了在血管病變檢查上有非常高的敏感度與特異性外，在足部與踝關節骨髓炎的確診與排除上，不僅扮演著非常重要的角色，也顯著優於Tc 99m 骨掃瞄、傳統X 光攝影、白血球掃瞄檢查(WBC scanning)等方法。針對血管病變，侵入性血管攝影除了提供最準確診斷外，也可直接對於病灶直接給予治療(PTA, percutaneous transluminal angioplasty經皮穿刺動脈腔內整形術)。
不管是可活動或長期臥床的老年人，若本身具有壓瘡風險因子，應特別留意預防足部壓瘡發生的機會。以本案例為例，當老人近期有功能退化(functional decline)，下肢末端傷口長期癒合不良，本身又有許多的共病症(comorbidity)，且傷口癒合不如預期時，應考慮下肢周邊動脈疾病(PAOD, peripheral arterial occlusive disease)的可能性。初步可先觸診兩側足部背動脈是否異常。而測量ABI(Ankle Brachial Index)是快速經濟的檢查方式，如有進一步檢查需要，儘早血管超音波檢查或核磁共振檢查。早期診斷早期治療，將可避免傷口惡化，甚至產生嚴重併發症。對於老年人功能恢復，也將會有非常顯著的益處。本案例原本惡化的傷口，在接受血管整型術、適當抗生素治療及傷口照護小組共同治療下漸漸復原，已退化的功能也經由老年醫學整合團隊(interdisciplinary team)周全性評估的介入下回復改善，目前已出院返家。
表一(Braden壓瘡危險因子評估表
壓瘡危險因子評估表 |
感覺知覺
說明：能對外來刺激做出有意義反映的能力 |
潮溼
說明：皮膚暴露於潮溼環境的程度 |
移動
說明：改變或控制身體姿勢的能力 |
活動
說明：執行物理活動的程度 |
營養
說明：一般的飲食狀況，以週為單位 |
磨擦力和剪力 |
1分－對疼痛刺激無反應，且無表情。 |
1分－皮膚很潮溼或更換尿片/床單＞3次/天 |
1分－在無人協助下無法移動肢體或身體 |
1分－絕對臥床 |
1分－
1.每餐進食量不超過整餐的1/3
2.除正餐外沒有補充任何點心
3. NPO，採清流質或靜脈輸液超過5天 |
1分－完全需人協助移動，無法坐起 |
2分－僅對疼痛刺激有反應，但無法溝通。 |
2分－皮膚常常潮溼或更換尿片/床單＜3次/天 |
2分－偶而在協助下稍移動肢體或身體 |
2分－僅限坐姿（輪椅） |
2分－
1.每餐進食量不超過整餐的1/2
2.偶爾吃點心
3.攝取的管灌飲食低於理想值 |
2分－需要少許的協助移動身體，經常躺在床上或坐在椅子上時偶會有下滑情形 |
3分－偶而可以口頭表達不適。 |
3分－皮膚偶爾潮溼或需要時才更換尿片/床單 |
3分－經常可獨立稍作移動肢體或身體 |
3分－偶而可行走 |
3分－
1.每餐進食量超過整餐1/2
2.有時拒絕用餐但會吃點心。
3.採用管灌(NG feeding)或靜脈營養(TPN) |
3分－有足夠的肌肉強度移動身體，在床上或椅子上可維持良好姿勢 |
4分－無感覺缺失的問題。 |
4分－乾燥、乾淨 |
4分－經常可獨立移動肢體或身體 |
4分－經常下床走動 |
4分－
每餐吃完，從不拒絕用餐，或不需任何補充食物 |
|
參考自: 國立成功大學醫學院附設醫院壓瘡預防與照護臨床照護指引Clinic Practice Guidelines for Pressure Ulcer Prevention and Care
表二
Braden scale score ≦18 |
|
糖尿病 |
全關節置換術病史 |
周邊動脈疾病 |
使用血管收縮藥物 |
腦血管疾病病史 |
|
低白蛋白 |
|
髖關節骨折病史 |
|
參考文獻
1. 沈惠民等。內科學誌 2011:22:254-65.
2. Okuwa M, Sanada H, Sugama J, et al. A prospective cohort studay of lower-extremity pressure ulcer risk among bedfast older adults. Adv Skin Wound Care. 2006;19:391-7.
3. Braden B, Bergstrom N. Braden Scale for predicting pressure sore risk. http://www.bradenscale.com/images/bradenscale.pdf Accessed October 1 2001
4. Thomas, D.R et al Existing tools: Are they meeting the challenges of pressure ulcer healing. Advances Skin Wound Care, 1997;10:86-90.
5. Imaging peripheral arterial disease: a randomized controlled trial comparing contrast-enhanced MR angiography and multi-detector row CT angiography. Radiology. 2005;236:1094-103.
6. Kapoor A, Page S, La Valley M, et al. Magnetic resonance imaging for diagnosing foot osteomyelitis A meta-analysis. Arch Intern Med 2007;167:125-32.
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Case Discussion
繼續教育考題