What are the recommended management strategies for bed sore (pressure ulcer) treatment?

Management Strategies for Pressure Ulcers (Bed Sores)

Effective management of pressure ulcers requires a combination of debridement, appropriate dressing selection, pressure offloading, and infection control to promote healing and reduce morbidity and mortality.

Core Treatment Strategies

Wound Cleaning and Debridement

• Clean the wound regularly with water or saline to remove debris and create an optimal healing environment 1
• Perform regular debridement with a scalpel to remove necrotic tissue, which is necessary for proper wound healing 1
• Surgical debridement is particularly important for infected pressure ulcers to remove all necrotic tissue 1

Dressing Selection

• Use hydrocolloid or foam dressings to reduce wound size and promote healing 1
• Hydrocolloid dressings are better than gauze dressings for reducing wound size (low-quality evidence) 1, 2
• Foam dressings (hydrocellular or polyurethane) have similar effectiveness to hydrocolloid dressings for complete wound healing 1, 2
• Control exudate to maintain a moist wound environment; a sterile, inert protective dressing is usually sufficient 1

Nutritional Support

• Provide protein or amino acid supplementation to reduce wound size, especially in nutritionally deficient patients 1
• Nutritional supplementation should be used in conjunction with standard therapies such as dressings or support surfaces 1
• Evidence does not show benefit of vitamin C supplementation compared with placebo 1

Pressure Offloading

• Implement complete pressure offloading from the affected area to minimize trauma to the ulcer site 1, 3
• Consider specialized support surfaces for pressure redistribution 4
• Air-fluidized beds may be superior to standard hospital beds for reducing pressure ulcer size 1, 4

Adjunctive Therapies

Electrical Stimulation

• Use electrical stimulation as adjunctive therapy to accelerate wound healing for stage 2 to 4 ulcers (moderate-quality evidence) 1
• Be aware that skin irritation is the most common adverse effect, with frail elderly patients being more susceptible to adverse events 1

Infection Management

• Assess for signs of infection such as increasing pain, erythema, warmth, or purulent drainage 1
• For infected pressure ulcers, use antibiotic therapy directed against both Gram-positive and Gram-negative facultative organisms as well as anaerobes, as these infections are typically polymicrobial 1
• Consider local antimicrobial therapy for superficial infections and systemic antibiotics for deeper or more severe infections 1, 5

Other Therapies with Limited Evidence

• Topical negative pressure therapy may hasten healing of post-operative wounds, but effectiveness and cost-effectiveness remain to be established 1
• Systemic hyperbaric oxygen therapy may increase healing incidence, though further studies are needed 1
• Evidence is insufficient for platelet-derived growth factor (becaplermin), bioengineered skin products, and other growth factors 1
• There is insufficient evidence to recommend silver-containing dressings or other antiseptic products in routine management 1, 5

Special Considerations

Monitoring and Assessment

• Regularly assess the wound for signs of healing or deterioration 3
• If the pressure ulcer is not showing signs of healing within 6 weeks despite optimal management, evaluate for vascular compromise 3
• For patients with heel ulcers, be particularly vigilant about infection control and vascular assessment 3

Prevention of Recurrence

• Develop a prevention plan once the ulcer is healed to avoid recurrence 3
• Consider the patient's overall health status and comorbidities that may affect healing, especially in elderly patients 1

Cautions and Pitfalls

• Avoid using advanced support surfaces like alternating-air and low-air-loss beds without clear indication, as evidence for their effectiveness is limited and they add unnecessary costs 1
• Be aware that dehiscence is a common complication following surgical repair of pressure ulcers, especially when bone is removed or with ischial ulcers 1
• Patients with spinal cord injury may have a higher rate of recurrent pressure ulcers after surgical closure 1
• Do not rely solely on intermediate outcomes like reduction in wound size, as the relationship between reduction in wound size and eventual complete healing is not well-defined 1