What actions should be taken to manage a Category 3 pressure ulcer on the sacrum in a patient with stage 3 chronic kidney disease and prevent further deterioration?

From the Guidelines

To manage a Category 3 pressure ulcer on the sacrum in a patient with stage 3 chronic kidney disease, implement a comprehensive wound care regimen that includes thorough wound assessment, regular cleaning, debridement, and application of appropriate dressings, while also addressing the patient's underlying condition and optimizing nutrition and pain management. The patient's wound care regimen should begin with a thorough wound assessment and regular cleaning using normal saline or pH-balanced wound cleanser 1. Debride necrotic tissue as needed, preferably through sharp debridement performed by a qualified healthcare professional. Some key considerations for managing the patient's pressure ulcer include:

• Applying appropriate dressings such as calcium alginates, hydrocolloids, or foam dressings, changing them when saturated or every 2-3 days 1
• Positioning the patient to completely offload pressure from the sacral area using specialized support surfaces like air-fluidized beds or alternating pressure mattresses, and implementing a strict turning schedule every 2 hours 1
• Optimizing nutrition with high-protein supplements (1.2-1.5 g/kg/day protein intake) while being mindful of phosphorus and potassium restrictions due to CKD 1
• Monitoring renal function regularly as wound healing may increase metabolic demands 1
• Assessing the wound weekly, documenting size, depth, appearance, and drainage 1
• Preventing infection through proper hand hygiene and aseptic technique during dressing changes, and promptly addressing signs of infection 1 It is also important to consider the patient's overall health and well-being, including their stage 3 CKD, when developing a comprehensive wound care plan. By taking a comprehensive approach to wound care and addressing the patient's underlying condition, it is possible to promote wound healing, prevent further deterioration, and improve the patient's quality of life.

From the Research

Management of Category 3 Pressure Ulcer

To manage a Category 3 pressure ulcer on the sacrum in a patient with stage 3 chronic kidney disease and prevent further deterioration, the following actions can be taken:

• Assess and optimize nutritional status to support wound healing 2
• Reposition the patient regularly to reduce pressure on the sacrum 2
• Provide appropriate support surfaces, such as a pressure-redistributing mattress or cushion 2
• Clean and debride the wound as necessary, and apply appropriate wound dressings based on the stage of the injury and the quality and volume of exudate 2
• Consider the use of negative pressure wound therapy (NPWT) to promote wound healing, although the evidence for its effectiveness is uncertain due to the lack of high-quality studies 3, 4, 5
• Monitor the wound for signs of infection, biofilms, and osteomyelitis, and manage these complications promptly if they occur 2

Use of Negative Pressure Wound Therapy

NPWT may be considered as an adjunct to standard wound care for the management of Category 3 pressure ulcers, particularly in patients with complex wounds or those who have not responded to conventional treatments. The use of NPWT with instillation and dwell (NPWTi-d) has shown promise in promoting wound healing and reducing the need for operative debridements and hospital length of stay 4. However, the evidence for the effectiveness of NPWT is limited by the small size and poor quality of available studies, and further research is needed to fully evaluate its benefits and risks 3, 5.

Considerations for Patients with Chronic Kidney Disease

Patients with stage 3 chronic kidney disease require careful management of their wound care, as they are at increased risk of complications such as infection and delayed healing. The use of topical hydrocolloid-based hydrogel dressings or honey may facilitate moist wound healing and debridement in these patients 6. Additionally, careful control of glycemic control, nutritional needs, and counterproductive behavior patterns is essential to optimize outcomes for individuals with chronic kidney disease and pressure ulcers 6.