What are non-invasive methods to prevent stool contamination in stage 4 decubitus (pressure) ulcers without using a diverting ostomy?

Non-Invasive Methods for Managing Stool Contamination in Stage 4 Pressure Ulcers

For patients with stage 4 decubitus ulcers, fecal management systems combined with negative pressure wound therapy (NPWT) offer an effective non-invasive alternative to diverting ostomy for preventing stool contamination and promoting wound healing. 1, 2

Fecal Management Systems

• Rectal diversion devices (silicone tubes) can effectively divert fecal matter away from sacral pressure ulcers, protecting wounds from contamination similar to a colostomy but without surgical intervention 1
• These devices can be used in combination with NPWT to effectively isolate the wound from fecal contamination 1
• Fecal management systems (FMS) like Flexi-Seal® have demonstrated effectiveness in managing fecal incontinence while limiting contact with the patient's skin, preventing further breakdown and promoting healing 2
• The soft flexible catheter conforms to the rectal vault, reducing the risk of necrosis while successfully diverting fecal fluid away from perineal tissue 2

Negative Pressure Wound Therapy Benefits

• NPWT can help wound healing physiologically once necrotic tissue is removed by increasing blood supply, improving tissue perfusion, reducing edema, and absorbing fluids and exudates 1
• NPWT can "splint" the wound to anchor drainage tubes, ensuring they remain close to the source of effluent to maximize fluid removal 1
• NPWT may protect skin from fecal output, helping to preserve the integrity of peri-wound skin 1
• NPWT promotes and accelerates granulation tissue formation by removing bacterial contamination and exudates 1

Combined Approach for Stage 4 Pressure Ulcers

• The combination of NPWT and fecal management systems has been successfully used in cases of deep decubital ulcers with fecal contamination, including those infected with Clostridium difficile 2
• For visible fistulae, NPWT can be used to achieve secure ostomy bag adhesion while simultaneously managing the adjacent wound 1
• For remote fistulae not suitable for direct stomal isolation, NPWT can be applied to the entire wound, allowing it to granulate and contract 1
• Foam dressing rather than gauze helps reduce local skin irritation caused by fecal contents (foam lifts drainage away from the skin, whereas gauze tends to trap it) 1

Wound Care Considerations

• Surgical debridement must be thorough to remove all necrotic tissue, which is essential before applying NPWT 1
• Wound contact layers (e.g., non-adherent silicon adherent layer) should be placed between the NPWT wound filler and the wound bed to prevent damage to underlying tissue during dressing changes 1
• Stoma adhesive powder or zinc oxide can be applied to areas with leakage to prevent local skin irritation 1
• Local fungal skin infections associated with leakage can be treated with topical antifungal agents 1

Effectiveness Compared to Colostomy

• Traditional colostomy for pressure ulcer management has shown limited success, with only 32% of patients achieving complete healing in one study despite undergoing the invasive procedure 3
• While colostomy creation has been associated with fewer species of gut microbiota cultured and lower rates of wound dehiscence after closure, the high mortality and low rate of pressure ulcer healing should temper enthusiasm for performing this invasive procedure 3, 4
• Teams caring for patients with pelvic osteomyelitis should strongly consider non-invasive fecal management approaches before resorting to diverting colostomy 1

Practical Implementation

• For patients with paraplegia and fecal incontinence, the combined approach of NPWT and fecal management systems should be implemented early to prevent wound contamination 1, 2
• Regular assessment of the wound and fecal management system is necessary to ensure proper function and prevent complications 2
• Wound and ostomy nurses are an invaluable resource in managing these complex wounds and should be consulted early in the treatment process 1

This approach offers a less invasive alternative to diverting ostomy while effectively managing the challenge of fecal contamination in stage 4 pressure ulcers, potentially improving patient outcomes and quality of life.