Decubitus (pressure) ulcers

Prevention

Repositioning is a significant part of prevention. A patient in an ordinary bed who is at risk for developing a pressure ulcer should be repositioned at frequent intervals; however, the correct timing for turning has never been established. The National Pressure Ulcer Advisory Panel (NPUAP) has admitted that evidence on repositioning every 2 hours is arbitrary and varies from country to country, even from facility to facility, and that repositioning at 2–4-hour intervals may be more appropriate.

Pillows and foam wedges are used to maintain an appropriate position and to keep bony prominences apart. Completely immobile patients should have their heels raised from the bed by a pillow or boot and not be placed on their trochanters, unless a specialized bed is used. To avoid the latter, use a 30-degree position from the horizontal lying on the side. The head of the bed should not be raised more than 30 degrees from the horizontal for an extended period. Knees should be flexed at 5–10 degrees to minimize the risk of deep-vein thrombosis.

Where possible, use lifting devices or draw sheets to reposition or to transfer patients. Minimize pressure from medical devices, such as catheters, oxygen tubing, and restraints. Finally, when appropriate, the patient should be placed on a pressure-reducing device such as alternating air, gel, or water mattress . Foam rings, foam cut-outs, or donut-style devices should not be used, as these devices distribute pressure inappropriately.

A patient sitting in a wheelchair should be repositioned frequently, perhaps every hour, and be taught to shift weight every 15 minutes. A pressure-reducing device made of foam, gel, air, or a combination of each is indicated. Unfortunately, even in paraplegics, the exact time interval for repositioning has never been accurately determined.

Barrier creams are useful for conserving the intact skin of incontinent patients and of those at risk for skin breakdown.

Theoretically, pressure ulcers should be preventable, but despite these measures, many simply are not. If they are associated with immobility, sustained pressure, and the loss of pain sensibility, these problems can and should be addressed. In practice, successful prevention is often foiled by our limited understanding of the pathogenesis, as well as by complicating comorbidities. There is also some evidence that many deep ulcers are initiated by multiple microthromboses of deep tissues. This indicates that dehydration, along with any factor that might increase blood coagulability, should be addressed.

Management

The management of skin lesions caused by pressure is based on these principles:

• Elimination of relative/sustained pressure

• Reposition of the patient regularly and frequently

• Removal of necrotic debris

• Maintenance of a moist wound environment

• Correction of the underlying contributing factors

• Nutritional supplements and screening for nutritional deficiencies

• Wound care with topical products and/or dressing

The patient should not lie on the ulcer. A patient who is at risk for developing additional ulcers and can assume a variety of positions without lying on the ulcer should be placed on a static support surface (i.e., air, foam, or water) . If the patient cannot assume various positions without lying on the ulcer or bottoms out while on a static surface, or if the ulcer does not heal after 2–4 weeks of optimal care, place the patient on a dynamic support surface when possible. These supporting surfaces can be categorized as constant low-pressure (CLP) devices conforming to body shaper or replacing pressure devices that alter pressure mechanically. CLP devices, such as high-specification foam mattresses with overlays, and bead-filled and water-filled mattresses, may lessen the development of pressure ulcers and tend to be more successful than standard foam hospital mattresses. Alternating-pressure (AP) mattresses and overlays include a variety of compartments filled with air inflating and deflating in a coordinated way to alter pressure continually across the body. Unfortunately, there is no proof to show exactly which type is better for protection and treatment; however, both CLP and AP devices are more successful than standard hospital mattresses for prevention and treatment.

Removal of Necrotic Debris

Debridement is required to expose granulation tissue, decrease infection risk, and improve healing, especially when there is an extensive eschar or necrotic tissue. Debridement can be conducted through surgical (sharp) and nonsurgical (enzymatic, autolytic, mechanical, and biologic). The debridement method is dependent on several factors, including the characteristics of the patient, the wound, the risk of infection risk, and even the cost.

Surgical debridement is indicated for infected ulcers with necrotic debris, if the patient has advancing cellulitis and systemic infection, devitalized tissue, and eschars other than those on the heel; however, the extent of tissue needing to be removed is highly variable. An eschar on the heel should be excised only if it is fluctuant, draining, or surrounded by cellulitis, and if the patient is septic. If there is a high index of suspicion that a biofilm is present (i.e., wound failing to heal despite proper wound care and antimicrobial therapy), then surgical debridement is required.

Major debridement is performed in the operating room, but serial sharp debridement can be performed at the bedside. The use of systemic antimicrobials should be considered to prevent bacteremia during significant debridement. A bone biopsy is recommended while debriding ulcers, when bone is exposed, and for non-healing deep ulcers (stage 3 or 4) after 2–4 weeks of optimal therapy.

Mechanical debridement methods, such as hydrotherapy, whirlpool baths, and wound irrigation are among other measures that have benefits, such as improving local circulation, reducing pain and fever, relieving debris and bacteria, helping with wound removal, and accelerating wound healing. Saline wet-to-dry gauze is an additional alternative.

Autolytic debridement provides a moist wound area that allows the body enzymes to digest necrotic tissue. Similarly, enzymatic debridement uses enzymes for the liquefaction of dead tissue in the wound and clears them with dressings like collagenase to remove necrotic tissue, and moist wounds are the best place for them to work. Autolytic and enzymatic debridement is indicated for non-infected ulcers that are unlikely to get infected.

Biologic debridement utilizes non-infectious larvae and maggots, which has been observed to have increased complete debridement over conventional therapy (80% versus 48%, respectively).

Maintenance of a Moist Wound Environment

The choice of a synthetic dressing depends on the presence of infection, amount of exudate, status of the periulcer skin, and amount of pain experienced by the patient. Saline dressings and alginates are indicated for infected ulcers. Synthetic dressings (i.e., films) are used on ulcers with minimal exudate, hydrocolloid wafers for moderate exudate, and foam wafers and alginates for ulcers with a large amount of exudate. Ulcers with fragile or dermatitic periulcer skin should be covered with hydrogel wafers or non-adherent foam wafers . All occlusive dressings relieve pain, when present, but the hydrogel wafers are best for this purpose.

Correction of the Underlying Contributing Factors

Attention to the medical status is important; diabetes mellitus, nutritional conditions (malnutrition, hypoproteinemia, anemia), peripheral vascular disease, deep venous thrombosis, congestive heart failure, lower extremity edema, cardiac disease, malignancy, mental health problems, and even Alzheimer disease may prevent any ulcer healing. Unfortunately, even the best medical care may not permit healing.

General Measures

Treatment of the pressure ulcer can be simplified and made more effective if the following recommendations are considered:

• It is essential that the heels are inspected at least daily and any changes are recorded

• Saline should be used to clean most pressure lesions; soap and disinfectants are too irritating for more than occasional use. Scrubbing may prove too irritating, so gentle washing is indicated

• When ulcers are not infected, synthetic dressings should be changed only if they become dislodged or wound fluid escapes from under the dressing

• Periulcer skin must be kept dry not only to avoid maceration but also to permit the dressing to adhere to the skin

• To obliterate dead space, fill deep ulcers loosely with a hydrocolloid, a hydrogel wound filler, or an alginate rope before applying a synthetic dressing. This same material should be placed under the edge of the ulcer when undermining is present. Bleeding after serial surgical debridement can often be controlled with an alginate dressing. Moistening with saline can loosen an alginate dressing that adheres to granulation tissue

• A clean ulcer failing to show signs of healing and revealing inflammatory signs of erythema, edema, and warmth, purulent discharge and persistent excessive exudate, discoloring or darkening of granulation tissue, giving off a foul odor, and presenting with heightened local pain should be treated with antibacterial agents, such as 1% silver sulfadiazine, cadexomer iodine, triple antibiotic, or retapamulin , for 2 weeks to reduce the bacterial burden; however, topical antimicrobials may create the risk of resistant bacterial strains emerging. Metronidazole gel would be the exception, as the odor of an infected ulcer can often be eliminated by applying it to the ulcer bed. Increased bacterial burden may impede healing before clinical signs of infection become apparent. Cytotoxic agents, such as hydrogen peroxide and povidone-iodine, should be avoided

• Clinical observation is the key to making the diagnosis. Cutaneous biopsies will not be helpful, although biopsies for aerobic and anaerobic bacteriology cultures could be useful if infection is suspected

• Systemic antibiotics are recommended only in the presence of bacteremia, sepsis, advancing cellulitis, or osteomyelitis. Bacterial testing and analysis with comprehensive swabbing cannot provide all the information required. Infection that is described as a variety of bacteria bigger than 10 ⁵ CFU/g of tissue is partially relevant. It is recommended the wound is controlled for signs of infections: pain, warmth, erythema, drainage, bad odor, and/or systemic manifestations. Osteomyelitis usually accompanies stage 4 pressure ulcers and deep ulcers. X-rays, MRI, and bone biopsy should be used to check for osteomyelitis

• Although most synthetic dressings relieve pain, treatment for moderate-to-severe pain can include topical anesthetics (lidocaine), non-steroidal antiinflammatory drugs, opiates, antidepressants, and sedatives

Dermatologic Observation

Observe for:

• Blanchable erythema

• Non-blanchable erythema

• Superficial ulcer

• Deep ulcer

• Eschar

• Necrosis

• Gangrene

• Decubitus dermatitis

Categories of Patients

Patients at risk need to be considered in terms of the underlying disease process:

• Spinal cord injury in an otherwise healthy person

• Neurologic disease with no medical disease but a devastating condition, such as multiple sclerosis or a cerebral vascular accident compromising the body integrity

• Debilitation with a multitude of medical diseases affecting the patient (e.g., arteriosclerosis, diabetes mellitus, Parkinson disease, Alzheimer disease, malignancy, malnutrition, and peripheral vascular disease)

• Surgical procedures requiring lengthy positioning on the operating table for cardiovascular or orthopedic procedures

Grading or Evaluation

Grading or evaluation can be accomplished by dermatologic observation and staging. Bear in mind that ulcer staging is arbitrary and does not reflect the dynamics of ulcer formation.

Staging

Stages are as follows:

• Stage 1: Non-blanchable erythema of intact skin

• Stage 2: Partial-thickness skin loss with exposed dermis. Adipose or deeper tissues are not exposed

• Stage 3: Full-thickness skin loss. Adipose tissue is visible in the ulcer bed, which may have undermining and tunneling (see figure)

• Stage 4: Full-thickness skin and tissue loss. Fascia, muscle, tendon, ligament, cartilage, or bone is exposed; undermining, tunneling, and epibole may be present

• Unstageable: Obscured full-thickness skin and tissue loss. Extent of tissue damage within the ulcer is obscured by slough or eschar and cannot be determined; removal of slough or eschar reveals a stage 3 or 4 pressure injury

• Deep tissue pressure injury: Persistent non-blanchable deep red, maroon, or purple discoloration (may be seen with intact or non-intact skin)

NPUAP recently have added two further pressure injury types to their definitions, both of which are caused by medical devices. Medical devices can lead to pressure injury and injury to mucosal membranes; staging is not possible for these types of pressure injury.

Most superficial ulcers do not progress to stage 2 or even 3 or 4 ulcers. The concept of staging need not be thought of as a progression.

Accumulating evidence suggests that a number of ulcers (most stages 3 and 4) may initially originate in the deep tissue compartment and progress outward to the dermis and epidermis (inside-out theory).

Pathophysiology

Risk Assessment Tools

Factors Predicting Pressure Ulcers