What are the management strategies for sacral ulcers?

Management Strategies for Sacral Ulcers

Air-fluidized beds, protein supplementation, hydrocolloid dressings, and electrical stimulation are the most effective interventions for managing sacral pressure ulcers based on current evidence. 1

Prevention and Initial Management

Positioning and Support Surfaces

• Early mobilization as soon as spine is stabilized 1
• Repositioning every 2-4 hours with pressure zone checks 1
• Use of high-level prevention supports:
  • Air-fluidized beds (superior for reducing ulcer size) 1
  • Air-loss mattress or dynamic mattress 1
  • Foam dressings (shown to be more effective than hydrocolloid dressings in preventing sacral pressure ulcers) 2

Daily Assessment

• Visual and tactile checks of all areas at risk at least once daily 1
• Use tools for pressure discharge (cushions, foam, pillows) to avoid interosseous contact 1
• When elevating backrest, consider semi-lateral positioning to minimize shear forces on existing sacral ulcers 3

Treatment Algorithm for Established Sacral Ulcers

Step 1: Assessment and Documentation

• Document size, location, depth, presence of eschar/granulation tissue, exudate, odor, sinus tracts, undermining, and infection 4
• Stage appropriately (I through IV) 4

Step 2: Nutritional Support

• Provide protein or amino acid supplementation to reduce wound size 1
• This intervention has moderate-quality evidence showing improved wound healing 1

Step 3: Wound Management

• For clean ulcers:

  • Apply hydrocolloid dressings (superior to gauze dressings for reducing ulcer size) 1
  • Consider foam dressings as an alternative (equivalent to hydrocolloid for complete wound healing) 1

• For infected/necrotic ulcers:

  • Perform debridement when necrotic tissue is present 4
  • Urgent sharp debridement if advancing cellulitis or sepsis 4
  • Consider negative pressure wound therapy with instillation and dwelling (NPWTi-d) for severe infections 5
  • Cleanse wounds preferably with normal saline 4

Step 4: Adjunctive Therapies

• Electrical stimulation to accelerate wound healing 1
  • Caution: May cause skin irritation, especially in frail elderly patients 1
• Consider platelet-derived growth factor for severe ulcers 1

Step 5: Surgical Management

• Consider surgical intervention for advanced-stage pressure ulcers 1
• V-Y advancement flap is commonly used for sacral pressure ulcers (simple technique applicable to most defect types) 6
• Primary closure may be considered if defective area is <16 cm 6
• Note: Sacral ulcers have lower recurrence rates after surgery compared to ischial ulcers 1

Important Considerations and Pitfalls

Infection Management

• Topical antibiotics if no improvement in healing after 14 days 4
• Systemic antibiotics for advancing cellulitis, osteomyelitis, or systemic infection 4
• Monitor for signs of osteomyelitis, which may require more aggressive intervention 5

Complications to Monitor

• Dehiscence (most common surgical complication) 1
• Recurrence (12-24% reoperation rate due to recurrence or flap failure) 1
• Skin irritation from dressings or electrical stimulation 1

Special Populations

• Patients with spinal cord injury have higher rates of recurrent pressure ulcers after surgical flap closure 1
• Frail elderly patients experience more adverse events with electrical stimulation 1

By following this structured approach to sacral ulcer management, clinicians can optimize outcomes while minimizing complications. The evidence strongly supports using air-fluidized beds, protein supplementation, appropriate dressings, and adjunctive therapies like electrical stimulation to promote healing and prevent recurrence.