What is the best treatment for a 95-year-old female with a stage four pressure ulcer on the sacrum?

From the Guidelines

The best treatment for a 95-year-old female with a stage four sacral pressure ulcer involves a comprehensive approach including wound care, pressure relief, nutritional support, and infection management, with a focus on improving quality of life and reducing morbidity and mortality.

Key Components of Treatment:

• Surgical debridement of necrotic tissue by a wound care specialist, as recommended by 1, followed by regular wound cleansing with normal saline or wound-specific cleansers.
• Dressing the wound with appropriate materials such as alginate dressings for heavily exudating wounds or hydrocolloid dressings for less exudative wounds, with dressing changes typically every 1-3 days depending on exudate levels.
• Pressure relief using a specialized pressure-redistributing surface (air-fluidized bed or alternating pressure mattress), repositioning every 2 hours, and avoiding direct pressure on the sacrum.
• Nutritional support providing 30-35 calories/kg/day, 1.2-1.5 g/kg/day of protein, and supplementation with vitamins A, C, and zinc if deficient, as suggested by 1.
• Pain management with scheduled acetaminophen (500-1000 mg every 6 hours) and as-needed opioids like oxycodone (2.5-5 mg every 4-6 hours).
• Targeted antibiotics based on wound culture results if infection is present, considering the polymicrobial nature of pressure ulcer infections as noted in 1.
• Discussion of treatment goals with the patient and family, considering quality of life and overall prognosis, and the potential challenges of complete healing and surgical interventions in advanced age.

Given the most recent and highest quality evidence from 1, which provides a comprehensive approach to the management of pressure ulcers, including the importance of a multidisciplinary team and consideration of the patient's goals of care, the treatment plan should prioritize the patient's quality of life, mobility, and comfort, while also addressing the wound infection and promoting healing.

From the Research

Treatment Options for Stage Four Pressure Ulcer

The treatment of a stage four pressure ulcer, particularly in a 95-year-old female, requires careful consideration of the patient's overall health, mobility, and nutritional status. The following options are based on available evidence:

• Surgical Treatment: According to 2, surgical treatment, such as a V-Y advancement flap, may be considered for sacral pressure ulcers. This method is simple and available for most types of defects. Primary closure may be considered if the defective area is small.
• Negative Pressure Wound Therapy (NPWT): 3 suggests that NPWT can be an effective treatment for sacral pressure ulcers, even in complex cases. However, it is essential to follow a treatment protocol that includes pathohistological assessment before application of NPWT and gradual increase of negative pressure.
• Wound Care and Dressings: 4 recommends the use of hydrocolloid dressings, which have been associated with almost three-times more complete healing compared to saline gauze. Other dressings, such as hydrogel and hydropolymer, may also be effective.
• Multidisciplinary Approach: 5 emphasizes the importance of a comprehensive and multidisciplinary approach to managing pressure ulcers, including assessment of the patient's underlying pathologies, nutritional status, and social support.
• Surgical Management: 6 describes a systematic approach to the surgical management of pressure ulcers based on staging, including preoperative management and 12 basic principles of pressure ulcer surgery.

Considerations for Treatment

When considering treatment options for a 95-year-old female with a stage four pressure ulcer, the following factors should be taken into account:

• Patient's Overall Health: The patient's underlying health conditions, mobility, and nutritional status should be assessed to determine the most suitable treatment option.
• Ulcer Location and Size: The location and size of the ulcer should be considered when selecting a treatment option. For example, sacral ulcers may require a different approach than ulcers on other areas of the body.
• Pain and Discomfort: The patient's level of pain and discomfort should be assessed and managed accordingly.
• Risk of Complications: The risk of complications, such as infection and sepsis, should be considered when selecting a treatment option.