Pressure ulcer

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

All patients should be treated with pressure relief, dietary optimisation, pain management, good hygiene practice, and skin care, particularly in the sacral region.[17][57][58]

Additional treatments should be applied to deep pressure ulcers (deep stage 3 or stage 4), and ulcers with signs of infection.

Photographs may be taken to document progress of wound healing during a hospital admission.

Pressure relief

Pressure relief is critical to pressure ulcer treatment and is achieved through repositioning and use of an appropriate support surface.

Patients should not be positioned on their wound. Guidelines recommend that repositioning frequency should be determined with consideration to the individual's level of activity, mobility and ability to independently reposition.[17] In many institutions, repositioning every 2 hours is the standard of care for at-risk individuals. This may, however, be difficult to achieve in a busy clinical setting, and use of prompting systems to encourage scheduled repositioning should be encouraged.[40]

Appropriate pressure-reducing aids, including mattresses and wheelchair or seat cushions, should be immediately provided. Little evidence supports the use of a specific support surface over other alternatives.[59][57] [ ]

Dietary optimisation

All patients at risk of pressure ulcers or who have pressure ulcers should be referred to a dietitian to ensure adequate total calorie and total protein intake.[60] A full nutritional assessment should be performed.[61]

An abbreviated nutritional assessment, as defined by the Nutrition Screening Initiative, should be performed at least every 3 months for patients at risk for malnutrition.[62] These include patients who are unable to take food by mouth or who experience an involuntary change in weight.

If normal feeding mechanisms and dietary supplements are insufficient to meet the nutritional needs of the patient, nutritional support (usually by tube feeding) should be used to place the patient into positive nitrogen balance (approximately 30-35 kcal/kg/day and 1.25 to 1.5 g of protein/kg/day). As much as 2 g of protein/kg/day may be needed in some instances, together with vitamin and mineral supplements, where deficiencies are suspected or confirmed.

Additional protein or amino acid supplementation may enhance healing; however, there is limited evidence to support this.[48][63] One small trial found that a nutritional formula enriched with arginine, zinc, and antioxidants led to improved healing.[64] Anabolic steroids have been used to promote weight gain and healing in patients with chronic wounds. However, a randomised clinical trial of oxandrolone in spinal cord injury patients with pressure ulcers failed to show any benefit compared with placebo.[65] [ ]

Management of pain

Assessment and management of pain is critical.[66]

Intermittent pain such as occurs at the time of wound debridement should be managed with an oral analgesic given 30 to 60 minutes before the procedure. Additionally, topical lidocaine applied to the wound may be of benefit.

Management of cyclic pain occurring at the time of a dressing change depends on the extent of the pain. Mild pain can usually be managed with paracetamol or a non-steroidal anti-inflammatory drug (NSAID). Moderate to severe pain is usually managed with an opioid. Codeine or oxycodone, often given in combination with paracetamol, can be used for moderate pain, while severe pain may require oral or intravenous morphine. These same medications may be used for persistent pressure ulcer pain.

Ibuprofen-releasing foam dressings or topical morphine applied to the ulcer pain may help alleviate cyclic pain; however, these therapies are not available as proprietary products, and may need to be compounded by a pharmacist.[67][68]

Hygiene, cleansing, and dressings

The aim of topical treatment is to achieve a clean wound bed, an essential precursor to healing.[69][70] If erythema or pus are seen, a wound swab may be taken swab the wound to obtain evidence of infection. While commonly used, wound swabs have not been shown to be useful in the management of potential infected pressure ulcers. Consequently, guidelines do not recommend routine use of wound swabs.[17]

The presence of excess moisture may exacerbate damage caused by frictional or shear force, so it is important to ensure that the skin of incontinent patients is regularly cleansed and dried and protective creams applied as appropriate.

There is little evidence to suggest which type of wound-cleansing solution or technique, wound dressing, or topical agent, is the most likely to heal pressure ulcers.[71][72]

Once the wound has been cleansed the choice of dressing is influenced by several factors, including the depth and size of the wound and the amount of exudate produced.[73] [ ]

A hydrocolloid dressing typically will provide a suitable environment to promote healing. Topical therapy should be chosen using a structured approach and determined by local policies and formularies.[74][75][73] Honey-impregnated dressings may be helpful in bacterial infection.[76]

Treatment of deep ulcers (deep stage 3 or stage 4)

Additional measures are indicated for stage 3 and stage 4 pressure ulcers.

Wound-bed preparation is key to healing of deep wounds.[77] If necrotic tissue or a thick layer of slough is present, the wound may require initial debridement by either: sharp debridement; autolytic debridement (using products such as hydrogels to facilitate autolysis); or the application of enzymatic agents, maggots, or high-pressure water jet.[78][69][79][80][81] There is no clear evidence on the most effective form of debridement.[82] However, if serious deep tissue infection is suspected, immediate sharp debridement is indicated.

Once free of necrosis, the wound should be dressed with suitable products to keep the wound bed moist and promote granulation and epithelialisation. [ ]

Surgery

May be considered in patients whose ulcers are not healing with conservative therapy or when rapid closure is desirable. Wounds are first subjected to extensive debridement followed by a suitable surgical procedure, determined by the location of the wound. Options may include ulcer excision, skin grafting, and flap formation. Recurrence rates can be high, even when patients are carefully selected. A diverting colostomy may be considered in the setting of faecal soilage of large sacral wounds, but the benefits have not been well defined.

Use of surgery must be balanced with risk of harm; a complication rate of 35% was reported in one analysis of 1248 patients who underwent pressure ulcer surgery.[83]

In patients due for surgery, the microbiological status of the wound should be reviewed and systemic antimicrobial cover provided where appropriate.

Management of infection

A wound containing quantities of necrotic tissue or slough will inevitably contain bacteria, typically Staphylococcus aureus, Proteus mirabilis, Pseudomonas aeruginosa, and certain Bacteroides species. A swab taken from such a wound will usually detect large numbers of organisms, a finding that may initiate unnecessary treatment with antibiotics. It has therefore been recommended that wounds should not be routinely swabbed.[17]

When there are clinical signs of infection that do not respond to treatment, radiological examination should be undertaken to exclude osteomyelitis and joint infection. Appropriate systemic antibiotic therapy should be initiated for patients with sepsis, advancing cellulitis, or osteomyelitis, all of which are potential complications of pressure ulcer.[84][85] In patients due for surgery, the microbiological status of the wound should be reviewed and systemic antimicrobial cover provided where appropriate.

Systemic antibiotics are not required for pressure ulcers that exhibit only clinical signs of local infection.[17] In these situations, topical antimicrobial therapy may be indicated. One systematic review emphasised that the effects of topical and systemic antimicrobial treatments remain unclear.[86] The routine use of medicated dressings in other circumstances is probably not indicated.[87] In patients due for surgery, the microbiological status of the wound should be reviewed and systemic antimicrobial cover provided where appropriate.

Adjunctive therapies

While a variety of adjunctive therapies exist that may potentially enhance wound healing, the evidence base for these interventions is mixed.[17]

Use of electrical stimulation therapy promotes cellular proliferation and enhances wound healing.[17][63][88] [ ]

Two randomised trials reported greater reductions in wound surface area among patients randomised to high frequency ultrasound (1 MHz) compared with standard care.[89][90]

There is insufficient evidence to demonstrate clinical benefit of vacuum therapy (or topical negative pressure therapy), although it is widely used.[91][92]

While hyperbaric oxygen therapy may provide short-term benefit for lower extremity diabetic ulcers, there is little evidence for its use in patients with pressure ulcers.[93][94]

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