What is the best course of action for a 73-year-old man with a stage IV sacral decubitus ulcer and exposed bone?

From the Guidelines

The best course of action for a 73-year-old man with a stage IV sacral decubitus ulcer with exposed bone is to refer him for debridement and bone biopsy, as recommended by the most recent and highest quality study 1. This approach is crucial in managing the severity of stage IV ulcers, which involve full-thickness tissue loss with exposed bone, tendon, or muscle, and carry significant risks of osteomyelitis and sepsis if not properly managed. The patient should be referred to a wound care specialist and surgical consultation for debridement of necrotic tissue and possible surgical intervention such as flap coverage. Pressure must be completely relieved from the sacral area using specialized air-fluidized or low air-loss beds, with regular repositioning every 1-2 hours. Nutritional support is critical, with high-protein supplements (providing at least 1.2-1.5 g/kg/day of protein) and adequate caloric intake (30-35 kcal/kg/day). Infection control measures include obtaining deep tissue cultures and initiating broad-spectrum antibiotics (such as vancomycin 15-20 mg/kg IV every 12 hours plus piperacillin-tazobactam 4.5g IV every 6 hours) if osteomyelitis is suspected, later narrowing therapy based on culture results, as suggested by 1 and 1. Wound care should include moist wound healing principles with advanced dressings like calcium alginates or hydrocolloids, changed daily or as needed. Pain management with scheduled acetaminophen 1000 mg every 8 hours and as-needed opioids may be necessary. This comprehensive approach is supported by various studies, including 1, 1, 1, and 1, which emphasize the importance of multidisciplinary management, proper wound care, and infection control in managing stage IV decubitus ulcers. Additionally, 1 highlights the need for careful evaluation and management of underlying conditions, such as osteomyelitis, to prevent recurrence and promote healing.

Some key points to consider in the management of this patient include:

• The importance of prompt referral to a wound care specialist and surgical consultation for debridement and possible surgical intervention
• The need for complete pressure relief and regular repositioning to promote healing and prevent further tissue damage
• The critical role of nutritional support in promoting wound healing and overall health
• The importance of infection control measures, including broad-spectrum antibiotics and deep tissue cultures, in managing osteomyelitis and preventing sepsis
• The use of advanced wound dressings and moist wound healing principles to promote wound healing and prevent infection.

Overall, the management of a stage IV sacral decubitus ulcer with exposed bone requires a comprehensive and multidisciplinary approach, with a focus on prompt referral, complete pressure relief, nutritional support, infection control, and advanced wound care.

From the Research

Best Course of Action

The best course of action for a 73-year-old man with a stage IV sacral decubitus ulcer and exposed bone is to refer for debridement and bone biopsy. This is because:

• Debridement is defined as the removal of nonviable material, foreign bodies, and poorly healing tissue from a wound, and it provides for removal of tissue with the highest bacterial count, reliable cultures, and identification of osteomyelitis 2.
• Surgical débridement is the quickest and most efficient way of getting the wound ready for healing, and it is key in achieving a clean, healthy, and free of infection wound 3.
• Adequate surgical debridement is the prerequisite for successful treatment of bone, joint and soft tissue infections, and different techniques are used according to the different textures of healthy, infected or necrotic tissue 4.
• Bone biopsies can be done during debridement of the overlying wounds, and the results of these bone cultures can actually affect subsequent antibiotic decisions, making it a helpful technique in certain cases 5.

Key Considerations

Some key considerations in this case include:

• The patient has a stage IV decubitus ulcer with exposed bone, which increases the risk of osteomyelitis and other complications.
• The patient has a history of stroke, type 2 diabetes, and hypertension, which can affect wound healing and increase the risk of complications.
• The patient is currently taking metformin, atorvastatin, aspirin, and lisinopril, which may need to be adjusted or monitored during treatment.
• The use of vancomycin or other antibiotics may be necessary to treat osteomyelitis or other infections, but it is important to consider the potential risks of nephrotoxicity and other side effects 6.

Next Steps

The next steps in this case would be to:

• Refer the patient for debridement and bone biopsy to remove nonviable tissue and identify any underlying infections.
• Monitor the patient's wound and overall condition closely, and adjust treatment as needed.
• Consider the use of antibiotics or other treatments to manage any underlying infections or complications.
• Work with a multidisciplinary team, including surgeons, infectious disease specialists, and other healthcare professionals, to develop a comprehensive treatment plan.