What is the recommended management for a patient with a bed sore (pressure ulcer)?

From the Guidelines

Management of a pressure ulcer involves a comprehensive approach focusing on pressure relief, wound care, and addressing underlying factors. First, reposition the patient every 2 hours to relieve pressure on affected areas and use pressure-redistributing surfaces like specialized mattresses or cushions 1. Clean the wound gently with saline solution during each dressing change, which should typically occur daily or as needed based on drainage. Debridement of necrotic tissue may be necessary, either through surgical, enzymatic (collagenase), autolytic, or mechanical methods. Apply appropriate dressings based on wound characteristics: hydrocolloids for shallow ulcers, hydrogels for dry wounds, alginates or foams for exudative wounds, and antimicrobial dressings if infection is present 1. Nutritional support is crucial, with adequate protein intake (1.25-1.5 g/kg/day) and sufficient calories to promote healing 1. Manage pain with appropriate analgesics, particularly before dressing changes. Infection requires treatment with topical antimicrobials for superficial infections or systemic antibiotics for deeper infections, guided by culture results. Document wound characteristics regularly, including size, depth, appearance, and drainage. Prevention of additional ulcers through regular skin assessment, moisture management, and minimizing friction and shear forces is essential. This multidisciplinary approach addresses the mechanical, biological, and systemic factors that contribute to pressure ulcer development and impair healing. Some key points to consider include:

• The use of advanced static mattresses and overlays is associated with a lower risk for pressure ulcers compared with standard mattresses in higher-risk patients 1.
• Alternating-air mattresses and overlays are not recommended due to the lack of evidence showing a potential benefit in the reduction of pressure ulcers in high-risk populations and their higher costs 1.
• Nutritional supplementation with protein or amino acids can improve the rate of wound healing 1.
• Hydrocolloid dressings are superior to gauze dressings for reducing wound size and are equivalent to foam dressings for complete wound healing 1.

From the Research

Management of Bed Sores (Pressure Ulcers)

The management of bed sores, also known as pressure ulcers, involves a comprehensive approach to prevent further injury and promote healing. Key aspects of management include:

• Regular repositioning of patients to prevent excessive pressure on a single area of the body 2
• Use of pressure-reducing surfaces and keeping the head of the bed at the lowest safe elevation to prevent shear 3
• Assessment of nutrition and provision of supplementation if needed 3
• Documentation of each ulcer, including size, location, and stage, to guide treatment 3

Treatment of Pressure Ulcers

Treatment of pressure ulcers involves:

• Management of local and distant infections, removal of necrotic tissue, and maintenance of a moist environment for wound healing 3
• Debridement, which may be performed using mechanical, enzymatic, or autolytic methods 3
• Wound cleansing, preferably with normal saline, and use of appropriate dressings 3
• Consideration of topical antibiotics if there is no improvement in healing after 14 days 3
• Systemic antibiotics for patients with advancing cellulitis, osteomyelitis, or systemic infection 3

Dressings and Topical Agents

The use of dressings and topical agents for treating pressure ulcers is a common practice, but the evidence for their effectiveness is limited:

• A network meta-analysis of 51 studies found that the evidence for the effectiveness of different dressings and topical agents is of low or very low certainty 4
• Some dressings, such as protease-modulating dressings, may increase the probability of pressure ulcer healing compared to saline gauze, but the evidence is not conclusive 4
• Further research is needed to determine which dressings or topical agents are most effective in promoting healing of pressure ulcers 4

Pharmacotherapy

Pharmacotherapy for pressure ulcers is limited, and the evidence for its effectiveness is unclear:

• Topical wound therapies have unclear benefits for patients with pressure ulcers 5
• Systemic therapies, such as oral pentoxifylline, may be effective in improving and healing venous leg ulcers, but their use in pressure ulcers is not well established 5
• Antimicrobial dressings, antiseptics, and antibiotics should be used judiciously to prevent bacterial resistance 5