What are the management and treatment options for pressure ulcers?

From the Guidelines

Management and treatment of pressure ulcers involves a comprehensive approach based on wound stage and patient condition, with the primary goal of promoting healing, preventing complications, and improving quality of life. The treatment plan should prioritize pressure relief through regular repositioning every 2-3 hours, specialized support surfaces like air mattresses, and proper positioning techniques 1.

Key Components of Pressure Ulcer Management

• Pressure relief: Regular repositioning and specialized support surfaces are crucial for preventing further pressure damage and promoting healing.
• Wound care: Gentle cleansing with saline or mild cleansers, debridement of necrotic tissue, and appropriate dressings based on wound characteristics are essential for wound healing.
• Infection management: Topical antimicrobials like silver-containing dressings for colonized wounds or systemic antibiotics for overt infection may be necessary.
• Nutritional support: Protein intake of 1.2-1.5 g/kg body weight daily, adequate hydration, and possibly vitamin C and zinc supplementation are vital for supporting the body's healing processes.
• Advanced therapies: Negative pressure wound therapy, growth factors like becaplermin gel, and biological dressings may be considered for non-healing ulcers.

Recommendations

• Use protein or amino acid supplementation to reduce wound size (Grade: weak recommendation, low-quality evidence) 1.
• Use hydrocolloid or foam dressings to reduce wound size (Grade: weak recommendation, low-quality evidence) 1.
• Use electrical stimulation as adjunctive therapy to accelerate wound healing (Grade: weak recommendation, moderate-quality evidence) 1.

Considerations

• The relationship between reduction in wound size or rate of healing and eventual complete healing has not been well-defined.
• Evidence was insufficient to determine the effectiveness or comparative effectiveness of various support surfaces, dressings, and adjunctive therapies.
• A multidisciplinary approach involving nurses, physicians, and other members of a care team is often necessary for effective treatment of pressure ulcers.

From the Research

Management and Treatment Options for Pressure Ulcers

• Pressure ulcers are localized injuries to the skin or underlying tissue, usually over a bony prominence, as a result of unrelieved pressure 2.
• Predisposing factors for pressure ulcers are classified as intrinsic (e.g., limited mobility, poor nutrition, comorbidities, aging skin) or extrinsic (e.g., pressure, friction, shear, moisture) 2.
• Prevention of pressure ulcers includes identifying at-risk persons and implementing specific prevention measures, such as:
  • Following a patient repositioning schedule
  • Keeping the head of the bed at the lowest safe elevation to prevent shear
  • Using pressure-reducing surfaces
  • Assessing nutrition and providing supplementation, if needed 2
• When an ulcer occurs, documentation of each ulcer (i.e., size, location, eschar and granulation tissue, exudate, odor, sinus tracts, undermining, and infection) and appropriate staging (I through IV) are essential to the wound assessment 2.
• Treatment of pressure ulcers involves:
  • Management of local and distant infections
  • Removal of necrotic tissue
  • Maintenance of a moist environment for wound healing
  • Possibly surgery 2
• Debridement is indicated when necrotic tissue is present, and urgent sharp debridement should be performed if advancing cellulitis or sepsis occurs 2.
• Mechanical, enzymatic, and autolytic debridement methods are nonurgent treatments 2.
• Wound cleansing, preferably with normal saline and appropriate dressings, is a mainstay of treatment for clean ulcers and after debridement 2.
• Bacterial load can be managed with cleansing, and topical antibiotics should be considered if there is no improvement in healing after 14 days 2.
• Systemic antibiotics are used in patients with advancing cellulitis, osteomyelitis, or systemic infection 2.

Dressings and Topical Agents for Treating Pressure Ulcers

• Dressings are widely used to treat pressure ulcers and promote healing, and there are many options to choose from, including alginate, hydrocolloid, and protease-modulating dressings 3.
• Topical agents have also been used as alternatives to dressings in order to promote healing 3.
• A network meta-analysis of 51 studies (2947 participants) found that the evidence is of low or very low certainty, and it is unclear which dressings or topical agents are the most likely to heal pressure ulcers 3.
• Foam dressings have been compared to other dressings, including hydrocolloid and hydrogel dressings, but the evidence is of very low certainty, and it is uncertain whether foam dressings are more clinically effective, more acceptable to users, or more cost-effective compared to alternative dressings 4.

Operative Debridement of Pressure Ulcers

• Operative debridement of pressure ulcers is safe, despite the medical co-morbidities in patients with severe pressure ulcers 5.
• Proper debridement technique may prevent sepsis and death in patients with multiple co-morbid conditions 5.
• Key steps in the debridement technique include:
  • Exposure of areas of undermining by excising overlying tissue
  • Removal of callus from wound edges
  • Removal of all grossly infected tissue
  • Obtaining a biopsy of the deep tissue after debridement of all nonviable or infected tissue for culture and pathology to determine the presence of infection, fibrosis, and granulation tissue 5.