What are the latest guidelines for managing sacral ulcers (pressure ulcers)?

Management of Sacral Pressure Ulcers

Use hydrocolloid or foam dressings as your primary wound dressing, provide protein supplementation at 1.2-1.5 g/kg/day, and implement immediate pressure redistribution with an air-fluidized bed or dynamic mattress. 1, 2

Immediate Pressure Relief (First Priority)

• Implement complete offloading of the sacral area using an air-fluidized bed or specialized pressure-redistribution surface, as air-fluidized beds demonstrate superior reduction in pressure ulcer size compared to standard hospital beds (moderate-quality evidence). 1, 3

• Reposition the patient every 2-4 hours with visual and tactile skin checks at least once daily, as the sacrum accounts for 39% of all pressure ulcers and requires vigilant monitoring. 2

• Mobilize the patient as soon as medically stable to reduce continuous pressure on the sacral region. 2

Wound Care Protocol

Primary Dressing Selection

• Apply hydrocolloid or foam dressings as the primary dressing, as these are superior to gauze dressings for reducing ulcer size (low-quality evidence for hydrocolloid superiority, moderate-quality evidence showing equivalence between hydrocolloid and foam). 1, 2

• Choose between hydrocolloid and foam based on exudate level—both are equally effective for complete wound healing. 2

• For moderate to heavy exudate in Stage 3 ulcers, consider alginate or hydrofiber dressings instead. 3

• Change dressings based on exudate levels, typically every 1-3 days. 3

Wound Cleansing and Debridement

• Cleanse the wound with normal saline or water at each dressing change—avoid harsh antiseptics that damage granulation tissue. 3

• Perform sharp debridement to remove all necrotic tissue and slough for Stage 3 or deeper ulcers, as this is essential for healing. 3

• Consider enzymatic debridement agents only if sharp debridement is contraindicated. 3

Nutritional Support (Critical Component)

• Provide protein supplementation at 1.2-1.5 g/kg/day, as moderate-quality evidence shows protein or amino acid supplementation improves wound healing rates. 1, 2, 3

• This recommendation applies specifically to patients with nutritional deficiencies; evidence may not generalize to well-nourished patients. 1

• Do not use vitamin C supplementation alone, as low-quality evidence shows no benefit compared to placebo. 1

Adjunctive Therapies

• Consider electrical stimulation as adjunctive therapy to accelerate wound healing for Stage 2-4 ulcers (moderate-quality evidence showing accelerated healing rate, though insufficient data on complete healing). 1, 2, 3

• The most common adverse effect is mild skin irritation; frail elderly patients are more susceptible to adverse events. 1

• For non-healing Stage 3 wounds, evaluate for negative pressure wound therapy, which may be useful in severe infections with good granulation formation. 3, 4

Stage-Specific Considerations

Stage 2 Sacral Ulcers

• Focus on hydrocolloid/foam dressings, pressure relief, and protein supplementation. 2
• Manage fecal and urinary incontinence aggressively, as moisture increases maceration risk in the sacral location. 2

Stage 3 Sacral Ulcers

• Document wound size, depth, slough presence, exudate amount, and surrounding skin condition at baseline and weekly. 3
• Apply antimicrobial dressings containing silver, iodine, or medical-grade honey to control biofilm (present in 80-90% of chronic wounds). 3
• Obtain wound cultures only when infection is clinically suspected, using the Levine technique for swab collection. 3
• Reassess the treatment plan if no improvement occurs within 2-4 weeks. 3

Surgical Considerations

• Sacral pressure ulcers have lower recurrence rates after surgery compared to ischial ulcers (12-24% reoperation rate due to recurrence or flap failure). 1, 2

• V-Y advancement flap is the most common surgical treatment for sacral ulcers due to its simplicity and versatility. 5

• Dehiscence is the most commonly reported surgical harm, occurring more frequently when bone is removed during surgery. 1

Critical Pitfalls to Avoid

• Do not use dextranomer paste—low-quality evidence shows it is inferior to other wound dressings for reducing ulcer area. 1, 2

• Do not use gauze dressings as primary dressings—they are inferior to hydrocolloid dressings. 3

• Do not obtain wound cultures routinely; only culture when infection is clinically suspected. 2

• Do not rely solely on intermediate outcomes (wound size reduction) without considering complete healing as the ultimate goal. 3

Monitoring Protocol

• Measure and document wound characteristics weekly to track progress. 3
• Monitor for signs of infection using clinical assessment (warmth, erythema, purulent drainage, odor). 3
• Implement strict hand hygiene and aseptic technique during all wound care procedures. 3