What are the management guidelines for bed sores (pressure ulcers) in Intensive Care Unit (ICU) patients?

Management of Bed Sores in ICU Patients

Use advanced static mattresses or overlays immediately for all ICU patients with existing pressure ulcers, and implement systematic repositioning every 2-4 hours with the 30-degree tilt position rather than standard lateral rotation. 1, 2

Risk Assessment and Initial Evaluation

• Perform risk assessment on all ICU patients upon admission using validated tools such as the Braden, Cubbin and Jackson, Norton, or Waterlow scales, though clinical judgment is equally effective. 1, 2
• Reassess risk regularly based on changes in clinical condition, particularly monitoring for key risk factors including older age, low body weight, cognitive impairment, physical limitations, incontinence, diabetes, edema, microcirculation impairment, and malnutrition. 1, 2
• Conduct thorough visual and tactile skin checks of all at-risk areas at least once daily, with particular attention to the sacrum, heels, ischium, and occiput. 2

Support Surface Selection

The evidence strongly favors advanced static mattresses over alternating-air systems:

• Use advanced static mattresses or advanced static overlays as first-line therapy for all ICU patients at increased risk or with existing pressure ulcers—these reduce ulcer incidence compared to standard hospital mattresses with no brand superiority demonstrated. 1
• Do not use alternating-air mattresses or alternating-air overlays as they show no clear benefit over static surfaces, cost significantly more, and add unnecessary noise and disruption. 1, 3
• For large pressure ulcers (>7 cm²), consider air-fluidized beds which showed median decrease in total surface area of -5.3 cm² versus +4.0 cm² increase with conventional therapy (p=0.01), with 5.6-fold greater odds of improvement. 4

Repositioning Protocol

Implement the following structured repositioning schedule:

• Reposition hemodynamically stable patients every 2-4 hours around the clock with pressure zone checks at each turn—this reduced pressure ulcer incidence from 15.1% to 5.2% (p<0.0001) in surgical ICU settings. 2
• Use the 30-degree tilt position rather than 90-degree lateral rotation when repositioning, as this reduces pressure on bony prominences (relative risk 0.62). 2, 3
• Avoid the flat supine position entirely as this concentrates pressure on vulnerable areas. 2
• Elevate the upper body ≥40 degrees in patients who can tolerate this position, while monitoring for hemodynamic effects. 2
• When using advanced pressure-reducing mattresses, repositioning intervals can be extended to 4 hours without increased ulcer incidence. 2
• Do not delay repositioning for hemodynamically stable patients—use of vasopressors or catecholamines is not a contraindication to position changes. 2

Critical caveat: For patients with increased intracranial pressure, position the head in a centered position and avoid lateral rotation during repositioning. 2

Wound Care for Existing Ulcers

Stage and document each ulcer systematically:

• Document size, location, depth, presence of necrotic tissue, eschar and granulation tissue, exudate amount, odor, sinus tracts, undermining, and signs of infection. 5, 6
• Stage appropriately (I through IV) as this is essential to wound assessment. 5

Local wound management:

• Clean wounds with water or normal saline—avoid harsh antiseptics that damage healing tissue. 3, 5
• Apply hydrocolloid dressings for Stage II blistered pressure ulcers as they are superior to gauze for reducing wound size and provide a moist healing environment. 3
• For exudate control, hydrocolloid or foam dressings are equivalent for complete wound healing. 3
• Consider silicone foam dressings for sacrum and heel ulcers as meta-analysis showed statistically significant reduction in HAPU incidence (effect size 4.62,95% CI: 0.05-0.29, p<0.00001). 7
• Avoid dressings with antimicrobial agents solely to accelerate healing (strong recommendation, low-quality evidence). 3

Debridement Strategy

Debride necrotic tissue when present:

• Perform urgent sharp debridement immediately if advancing cellulitis or sepsis occurs. 5, 3
• For non-urgent situations, use mechanical, enzymatic, or autolytic debridement methods. 5
• In hospice or end-of-life patients, avoid aggressive sharp debridement unless there is advancing cellulitis or sepsis—the pain and trauma may outweigh benefits. 3

Infection Management

Use a tiered approach to infection:

• Manage bacterial load initially with wound cleansing alone. 5
• Consider topical antibiotics if no improvement in healing after 14 days of optimal wound care. 5
• For superficial infection signs (increased erythema, warmth, purulent drainage), consider topical antimicrobial therapy. 3
• Reserve systemic antibiotics for advancing cellulitis, osteomyelitis, or systemic infection (fever, hypotension, altered mental status)—these infections are typically polymicrobial requiring coverage of Gram-positive, Gram-negative, and anaerobic organisms. 5, 3

Nutritional Support

• Provide protein or amino acid supplementation for patients with nutritional deficiencies who can tolerate oral intake, as this may reduce wound size (weak recommendation, low-quality evidence). 3, 2
• Avoid vitamin C supplementation alone as it shows no benefit over placebo. 3

Early Mobilization

• Begin mobilization as soon as the patient is medically stable—early mobilization is defined as within 72 hours of ICU admission. 2
• Start with passive range-of-motion exercises for at least 20 minutes per zone, even in patients who cannot actively participate. 2
• Progress to active mobilization using a structured protocol that aims for the highest achievable mobility level at each session. 2

Skin Care and Adjunctive Measures

• Keep skin clean and dry at all times, addressing incontinence promptly as urinary or fecal incontinence increases skin maceration and ulcer risk. 2
• Apply barrier sprays and lubricants judiciously to protect skin from friction during repositioning. 2
• Apply pressure-relieving devices including specialized cushions, foam, and pillows to avoid interosseous contact, particularly at the knees. 2

Implementation Framework

Establish a multicomponent prevention program that includes:

• Simplification and standardization of pressure ulcer interventions and documentation. 1, 2
• Multidisciplinary team involvement with designated leaders for pressure ulcer prevention. 1, 2
• Designated "skin champions" to educate personnel on preventive care and reinforce proper repositioning technique. 2
• Ongoing staff education programs on pressure ulcer prevention. 2
• Sustained audit and feedback on pressure ulcer rates with regular all-facility meetings. 2
• Document each position change with time and skin assessment findings to ensure adherence. 2

This bundled approach has demonstrated cost savings of approximately $11.5 million annually in hospital systems while significantly reducing pressure ulcer prevalence. 2

Reassessment and Treatment Modification

• Perform regular reassessment of wound characteristics and comfort, with documentation of changes over time to guide treatment modifications. 6
• If no improvement in comfort or healing is observed within 6 weeks despite optimal management, reevaluate the treatment approach. 6
• The PUSH score combined with symptom assessment can be used to evaluate intervention effectiveness and demonstrate treatment response. 6