What are the guidelines for inpatient management of decubitus (pressure) ulcers?

Inpatient Management of Decubitus Ulcers

The management of pressure ulcers requires a comprehensive approach that includes pressure relief, wound care, nutritional support, and consideration for surgical intervention when appropriate, with electrical stimulation recommended as an adjunctive therapy for stage 2 ulcers and surgical evaluation for stage 3-4 ulcers. 1

Risk Assessment and Initial Management

• Use validated risk assessment tools such as Braden, Norton, or Waterlow scales to identify at-risk patients 1
• Implement regular repositioning every 2-4 hours, using 30-degree tilted positions to relieve pressure on vulnerable areas 1
• Use advanced static mattresses or overlays rather than standard hospital mattresses for patients at risk 1
• Avoid alternating-air mattresses as they show no clear benefit over static air mattresses and are more expensive 1

Wound Care Approach

Assessment and Documentation

• Document each ulcer's characteristics: size, location, presence of eschar and granulation tissue, exudate, odor, sinus tracts, undermining, and signs of infection 1
• Stage ulcers appropriately (I through IV) to guide treatment decisions 1

Debridement

• Remove necrotic tissue when present to promote healing 2
• Perform urgent sharp debridement if advancing cellulitis or sepsis occurs 3
• For non-urgent cases, consider mechanical, enzymatic, or autolytic debridement methods 3

Dressing Selection

Based on wound characteristics:

• Hydrocolloid dressings: For wounds with minimal exudate; reduce ulcer size compared to gauze dressings (low-quality evidence) 2, 1
• Foam dressings: For wounds with moderate exudate 1
• Alginate/Hydrofiber dressings: For wounds with heavy exudate 1

Nutritional Support

• Provide protein-containing supplements to improve wound healing (moderate-quality evidence) 2, 1
• Target protein intake of 1.2-1.5 g/kg/day to enhance tissue integrity and healing 1
• Vitamin C supplementation has not shown benefit (low-quality evidence) 2

Adjunctive Therapies

• Electrical stimulation: Recommended to accelerate wound healing as an adjunctive therapy (moderate-quality evidence) 2, 1
• Negative pressure wound therapy: May be beneficial but has mixed or limited evidence (low-quality evidence) 2, 1
• Other therapies with limited or mixed evidence include:
  • Electromagnetic therapy 2
  • Therapeutic ultrasound 2
  • Light therapy 2, 1
  • Laser therapy 2

Infection Management

• Monitor for signs of infection, including spreading cellulitis and systemic symptoms 1
• Use topical antibiotics if there's no improvement in healing after 14 days 3
• Administer systemic antibiotics for advancing cellulitis, osteomyelitis, or systemic infection 3

Surgical Intervention

• Consider surgical evaluation for stage 3 or 4 ulcers that fail to respond to conservative management 1
• Be aware that reoperation rates due to recurrence or flap failure range from 12% to 24% 1
• Note that dehiscence is more common if bone is removed during surgery 1
• Patients with sacral pressure ulcers have lower recurrence rates after surgery than those with ischial pressure ulcers (low-quality evidence) 2
• Patients with spinal cord injury have higher rates of recurrent pressure ulcers after surgical flap closure (low-quality evidence) 2

Monitoring and Documentation

• Perform daily wound inspection and documentation of wound characteristics and healing progress 1
• Document all assessments and interventions to guide treatment decisions 1
• Implement multicomponent interventions including standardized care protocols, staff education, and regular audits 1

Common Pitfalls and Caveats

• Air-fluidized beds reduce pressure ulcer size compared with other surfaces (moderate-quality evidence), but outcomes don't differ significantly between other support surfaces 2
• Avoid focusing solely on wound care without addressing the underlying causes of pressure ulcers (immobility, poor nutrition, etc.) 4
• Not all pressure ulcers are preventable or curable, particularly in patients with poor circulation or cognitive impairment 4
• Recognize that patients with spinal cord injury may require more intensive monitoring due to higher recurrence rates 2