Please write admission orders for a patient with a Stage IV sacral pressure ulcer and suspected osteomyelitis.

Admission Orders for Stage IV Sacral Pressure Ulcer with Suspected Osteomyelitis

Admit this patient to a multidisciplinary wound care service with immediate surgical consultation, initiate comprehensive nutritional support (30-35 kcal/kg/day, 1.25-1.5 g protein/kg/day), obtain MRI for osteomyelitis evaluation, and withhold systemic antibiotics unless there are clear signs of soft tissue infection or systemic sepsis. 1

Admission Status & Service

• Admit to: Wound care/plastic surgery service
• Level of care: Medical-surgical floor (unless septic, then ICU)
• Code status: Confirm with patient/family
• Consultations:
  • Plastic surgery (for surgical planning)
  • Infectious disease
  • Nutrition/dietitian (mandatory)
  • Physical therapy/occupational therapy
  • Social work (assess barriers to care, housing stability, support systems)

Diagnostic Workup

Imaging

• MRI of pelvis/sacrum (preferred modality, sensitivity 94% but specificity only 22% - interpret cautiously) 1
  • If MRI contraindicated: CT pelvis with contrast
  • Do NOT order bone scan - poor specificity, cannot differentiate infection from bone remodeling 1
  • Ultrasound for soft tissue abscess evaluation if clinically indicated 1

Laboratory Studies

• CBC with differential
• CRP and ESR (baseline for trending, not diagnostic)
• Comprehensive metabolic panel (assess renal function, albumin)
• Albumin, prealbumin
• Hemoglobin A1c (if diabetic or unknown status)
• Vitamin D, B12, folate, zinc levels 1
• Blood cultures x2 if febrile or signs of systemic infection

Microbiological Sampling

• Do NOT obtain superficial wound swabs - low sensitivity/specificity 2
• Obtain deep tissue cultures ONLY if:
  • Signs of soft tissue infection present (wound dehiscence, bridging, undermining, pocketing, purulent drainage, erythema/edema, temperature elevation) 1
  • Surgical debridement planned - obtain intraoperative bone biopsy for culture AND histopathology 1
• Use NERDS/STONES criteria to assess for infection 1:
  • NERDS: Nonhealing, Exudate, Red friable tissue, Debris, Smell
  • STONES: Size increasing, Temperature elevation, Os (probes to bone), New breakdown, Erythema/Edema, Exudate, Smell

Antibiotic Orders

Critical decision point: Exposed bone does NOT equal osteomyelitis (prevalence 17-58% in Stage IV ulcers) 1

If NO signs of soft tissue infection or systemic sepsis:

• Hold all systemic antibiotics 1
• Osteomyelitis without soft tissue infection does not require antibiotics if no surgery planned 1

If soft tissue infection present WITHOUT abscess:

• Start empiric antibiotics covering S. aureus (including MRSA), Enterococcus, gram-negatives, anaerobes 1
• Duration: 5 days (extend only if slow improvement) 1
• Example regimen: Vancomycin 15-20 mg/kg IV q8-12h + piperacillin-tazobactam 3.375g IV q6h
• Adjust based on local antibiogram (consider MRSA prevalence, MDR gram-negatives) 1

If cutaneous abscess present:

• Surgical drainage required
• Antibiotics for 5-10 days post-drainage 1

If pyomyositis:

• 14-21 days with abscess drainage 1

Post-surgical debridement with flap reconstruction:

• 6 weeks of targeted antibiotics based on intraoperative bone cultures 1
• Oral therapy acceptable in select patients 1
• Recent evidence suggests 4-6 weeks may be adequate 3

Pressure Relief & Wound Care

Pressure Offloading

• Specialty pressure-redistribution mattress (low air loss or alternating pressure)
• Complete pressure offloading of sacrum - patient positioning:
  • Side-to-side turning q2h
  • 30-degree lateral positioning (avoid direct sacral pressure)
  • NO supine positioning until cleared by wound team
• Specialty wheelchair cushion evaluation by OT
• Pressure mapping if available

Wound Management (T.I.M.E. Principle) 1

T - Tissue Debridement:

• Sharp debridement at bedside for necrotic tissue/eschar
• Surgical debridement if extensive involvement

I - Infection/Inflammation Control:

• Stabilized hypochlorous acid wound cleanser (noncytotoxic, germicidal) 1
• Medical-grade honey or silver dressings if biofilm suspected
• Target wound pH 4-6 1

M - Moisture Control:

• Hydrogel or hydrocolloid dressings
• Negative pressure wound therapy (NPWT) if appropriate wound bed

E - Epithelial Advancement:

• Monitor for healing arrest
• Consider growth factors/platelet-rich plasma if stalled

Dressing Orders

• Clean wound with stabilized hypochlorous acid solution daily
• Apply [specific dressing based on wound characteristics]
• Change dressing daily or per wound care team recommendations
• Document wound measurements weekly (length, width, depth, undermining)

Nutritional Support (MANDATORY) 1

• Caloric goal: 30-35 kcal/kg/day
• Protein goal: 1.25-1.5 g/kg/day
• Supplementation:
  • Vitamin C 500mg PO BID
  • Vitamin D 2000 IU PO daily (adjust based on levels)
  • Zinc 220mg PO daily
  • B-complex vitamins
  • Consider arginine, glutamine, HMB supplementation 1
• Hydration: Minimum 30 mL/kg/day (improves microvascular perfusion) 1
• Dietary consult for individualized meal planning
• Weekly weights, adjust intake based on weight trends
• Consider enteral nutrition if unable to meet goals orally

Bowel/Bladder Management

Fecal Incontinence

• If incontinent of stool: Aggressive bowel regimen to prevent contamination
• Consider fecal management system short-term
• Surgical consultation for diverting colostomy if:
  • Recurrent contamination despite measures
  • Patient has paraplegia 1
  • Flap reconstruction planned

Urinary Management

• Intermittent catheterization preferred over indwelling catheter (if spinal cord injury) 1
• If indwelling catheter necessary, change q2-4 weeks

Medication Reconciliation

Review and HOLD/REDUCE if possible (after multidisciplinary discussion): 1

• Corticosteroids
• Immunomodulators (TNF-α inhibitors)
• Chemotherapy agents
• Document rationale if cannot be discontinued

Pain Management

• Multimodal approach
• Avoid NSAIDs (impair wound healing)
• Acetaminophen 650mg PO q6h scheduled
• Opioids as needed for breakthrough pain
• Gabapentin if neuropathic component

Activity Orders

• Physical therapy evaluation
• Bed mobility training
• Pressure relief education
• NO sitting until cleared by wound team
• Fall precautions

Monitoring

• Daily wound assessment by nursing
• Weekly wound measurements and photography
• Monitor for signs of infection (temperature, wound changes, systemic symptoms)
• Weekly labs: CBC, CRP, albumin
• Daily weights

Surgical Planning Discussion

Key decision: Is patient a surgical candidate? 1

Assess surgical eligibility:

• Goals of care discussion
• Nutritional status (albumin >2.5 g/dL target)
• Medical optimization
• Smoking cessation if applicable
• Glycemic control if diabetic (HbA1c <8%)

Surgical approach considerations:

• 1-stage: Debridement + immediate/early flap (within 48h) 1
• 2-stage: Debridement, then delayed flap 4-6 weeks later (better hemostasis, lower hematoma risk) 1

Specific surgical considerations for sacral location: 1

• Most commonly affects lower sacral segments (below S3/S4)
• Risk of CSF leak if dural tube violated
• Preserve S2-S4 nerve roots (sphincter function) in non-paraplegic patients
• Diverting colostomy strongly considered in paraplegic patients 1

Discharge Planning (Start on Admission)

Address barriers to care: 1

• Stable housing assessment
• Home care support availability
• Access to specialty mattress/wheelchair
• Transportation for follow-up
• Mental health screening (depression, coping mechanisms)
• Financial/insurance barriers

Common Pitfalls to Avoid:

1. Do not treat osteomyelitis with antibiotics alone if no surgery planned - outcomes are poor regardless 4
2. Do not rely on superficial wound cultures - obtain deep bone samples intraoperatively 2
3. Do not assume exposed bone = osteomyelitis - prevalence only 17-58% 1
4. Do not use prolonged antibiotics as bridge to delayed surgery - no benefit 1
5. Do not neglect social determinants - inadequate home support predicts treatment failure 2

Prognostic Counseling:

Set realistic expectations: Even with optimal treatment, 1-year outcomes show 63% readmission rate, 44% osteomyelitis-related readmission, and 17% mortality 4. Treatment failure occurs in 71% and ulcer healing in only 36% without surgical reconstruction 2.