What are the steps to manage a patient with a stage 3 sacral pressure injury?

Management of Stage 3 Sacral Pressure Injury: A Comprehensive Approach

The management of a stage 3 sacral pressure injury requires a multidisciplinary approach focusing on wound assessment, debridement, appropriate dressing selection, pressure redistribution, and nutritional optimization to promote healing and prevent complications. 1

Initial Assessment and Staging

• Confirm stage 3 classification: Full-thickness tissue loss exposing subcutaneous fat (bone, muscle, and tendon not visible); slough may be present but does not obscure the depth of tissue loss 1
• Assess for:
  • Signs of local infection: increased pain, erythema, edema, increased warmth, purulent drainage, malodor
  • Signs of biofilm: low-level chronic inflammation, delayed healing despite adequate care, increased exudate, poor granulation
  • Signs of systemic infection: fever, chills, elevated white blood cell count, hypotension 2

Step-by-Step Management Protocol

1. Wound Cleansing and Debridement

• Gently cleanse the wound with saline or appropriate wound cleanser at each dressing change
• Perform debridement to remove necrotic tissue and biofilm:
  • Sharp debridement for visible necrotic tissue (performed by qualified clinician)
  • Enzymatic debridement may be used as an alternative
  • Mechanical debridement with irrigation for loose debris 1, 2

2. Wound Dressing Selection

• Select moisture-balanced dressings appropriate for stage 3 wounds:
  • Alginate or hydrofiber dressings for moderate to heavy exudate
  • Hydrocolloid dressings for light to moderate exudate
  • Consider antimicrobial dressings (silver, iodine, PHMB) if signs of local infection or biofilm are present 2, 3
• Change dressings based on exudate levels and manufacturer recommendations (typically every 1-3 days)

3. Pressure Redistribution and Positioning

• Implement a turning schedule every 2 hours
• Use pressure-redistributing surfaces:
  • Specialized foam, air, or gel mattress/overlay
  • Avoid positioning directly on the affected area
  • Use pillows or foam wedges to maintain 30-degree side-lying position when not prone 1, 2
• Avoid dragging the patient during repositioning to prevent shear forces

4. Nutritional Optimization

• Ensure dietary intake of 30-35 kcal/kg/day and 1.25-1.5 g protein/kg/day
• Supplement with micronutrients that enhance wound healing:
  • Vitamin B6, B12, folate
  • Zinc, vitamin C, vitamin D
  • Arginine supplements may be beneficial 1, 2
• Maintain adequate hydration

5. Infection Management

• Obtain wound cultures if clinical signs of infection are present
• Initiate topical antimicrobials for local infection
• Reserve systemic antibiotics for patients with:
  • Spreading cellulitis
  • Systemic inflammatory response
  • Suspected deep tissue infection 1

6. Monitoring and Reassessment

• Document wound measurements, appearance, and characteristics weekly
• Take wound photographs to track progress
• Reassess treatment plan if no improvement is observed within 2 weeks
• Monitor for deterioration to stage 4 (bone exposure) which would require surgical evaluation 1, 2

Surgical Considerations

• Surgical consultation should be considered if:

  • The wound fails to improve with conservative management
  • The wound progresses to stage 4 with bone exposure (potential osteomyelitis)
  • There is extensive undermining or tunneling 1

• Surgical options may include:

  • Debridement of necrotic tissue
  • V-Y advancement flap (common for sacral pressure injuries) 4
  • Lumbosacral rotation flap for larger defects 5

Prevention of Recurrence

• Continue pressure redistribution measures even after healing
• Implement a skin inspection schedule
• Maintain optimal nutrition and hydration
• Provide education to patient and caregivers on prevention strategies 1

Common Pitfalls to Avoid

• Neglecting to assess for biofilm, which can significantly delay healing
• Using inappropriate dressings that don't manage exudate effectively
• Failing to address nutritional deficiencies
• Overuse of antibiotics without clear evidence of infection
• Inadequate pressure redistribution despite wound care interventions 1, 2

By following this systematic approach to managing stage 3 sacral pressure injuries, clinicians can promote optimal healing conditions, prevent complications, and reduce the risk of progression to more severe stages.