What is the management for decubital (pressure) ulcers?

Management of Decubital (Pressure) Ulcers

The cornerstone of pressure ulcer management is complete pressure offloading combined with protein supplementation, hydrocolloid or foam dressings, and regular wound debridement, with electrical stimulation as effective adjunctive therapy to accelerate healing. 1, 2

Pressure Redistribution (Primary Intervention)

• Use advanced static mattresses or overlays as the first-line pressure redistribution surface, as they provide adequate pressure relief at lower cost compared to alternating-air systems 3
• Air-fluidized beds are superior to standard hospital beds for reducing pressure ulcer size when advanced static surfaces are insufficient 1, 2
• Alternating-air beds and low-air-loss mattresses do not show substantial benefit over other surfaces for reducing wound size and add unnecessary cost 1, 3
• Implement complete pressure offloading from the affected area through repositioning or specialized surfaces 2
• When repositioning is performed, use the 30-degree tilt position rather than 90-degree lateral rotation to reduce pressure on bony prominences 3

Nutritional Support

• Provide protein or amino acid supplementation to all patients with pressure ulcers, particularly those with nutritional deficiencies, as this reduces wound size 1, 2
• High protein oral nutritional supplements (30 energy percent) reduce the risk of developing new pressure ulcers (OR 0.75; 95% CI 0.62–0.89) 1
• Formulas with higher protein content (24 energy percent vs 14 energy percent) are more successful in decreasing total pressure ulcer surface area 1
• Do not use vitamin C supplementation alone, as it shows no benefit over placebo 1, 3
• Consider supplements containing zinc, arginine, carotenoids, and vitamins A, C, and E for wound healing support 1

Wound Care and Dressings

• Clean the wound regularly with water or saline to remove debris and create optimal healing environment; avoid harsh antiseptics that damage healing tissue 3, 2
• Use hydrocolloid or foam dressings as primary treatment, as hydrocolloid dressings are superior to gauze for reducing wound size 1, 3, 2
• Hydrocolloid and foam dressings are equivalent for complete wound healing 1, 3
• Control exudate with appropriate dressings to maintain a moist wound environment 3, 2
• Avoid dextranomer paste, as it is inferior to other wound dressings for reducing ulcer area 1

Debridement

• Perform regular debridement with a scalpel to remove necrotic tissue, which is necessary for proper wound healing 2
• Surgical debridement is particularly important for infected pressure ulcers to remove all necrotic tissue 2
• In hospice or end-of-life patients, avoid aggressive sharp debridement unless there is advancing cellulitis or sepsis, as pain and trauma may outweigh benefits 3

Adjunctive Therapies

• Use electrical stimulation as adjunctive therapy to accelerate wound healing for stage 2 to 4 ulcers (moderate-quality evidence) 1, 2
• Electrical stimulation produces similar results across different healthcare settings and patient populations 1
• Be aware that frail elderly patients are more susceptible to adverse events (skin irritation) with electrical stimulation 1
• Avoid electromagnetic therapy, therapeutic ultrasound, negative-pressure wound therapy, light therapy, and laser therapy as routine adjuncts, as evidence shows no difference or mixed findings compared to controls 1

Infection Management

• Assess for signs of infection including increasing pain, erythema, warmth, or purulent drainage 2
• Reserve systemic antibiotics for advancing cellulitis, osteomyelitis, or systemic infection (fever, hypotension, altered mental status) 3
• Use antibiotic therapy directed against Gram-positive and Gram-negative facultative organisms as well as anaerobes, as these infections are typically polymicrobial 3, 2
• Consider topical antimicrobial therapy for superficial infection signs (increased erythema, warmth, purulent drainage) 3
• Avoid dressings with antimicrobial agents solely to accelerate healing (strong recommendation, low-quality evidence) 3

Biological Agents

• Platelet-derived growth factor (PDGF) improves ulcer healing compared with placebo for more severe ulcers (>7 cm) 1
• Evidence is insufficient for other growth factors and bioengineered skin products 2

Monitoring and Reassessment

• If the pressure ulcer shows no signs of healing within 6 weeks despite optimal management, evaluate for vascular compromise 2
• Regularly assess the wound for signs of healing or deterioration 2
• The relationship between reduction in wound size and eventual complete healing is not well-defined, so monitor for complete wound closure as the ultimate goal 1, 2

Surgical Considerations

• Surgery is an option for advanced-stage pressure ulcers when conservative management fails 1
• Be aware that dehiscence is common following surgical repair, especially when bone is removed and in patients with ischial ulcers 1, 2
• Patients with sacral pressure ulcers have lower recurrence rates after surgery than those with ischial pressure ulcers 1
• Patients with spinal cord injury have higher rates of recurrent pressure ulcers after surgical flap closure 1, 2

Common Pitfalls

• Do not rely on support surfaces alone to eliminate all pressure from the wound; active repositioning and pressure relief remain essential 4, 5
• Avoid using intermediate outcomes like wound size reduction as the sole measure of success; complete wound healing is the ultimate goal 1, 2
• Recognize that not all pressure ulcers are preventable, particularly in patients with poor circulation, cognitive impairment, or severe multimorbidity 5
• Address underlying risk factors including malnutrition, poor circulation, pain, and immobility as part of comprehensive management 5, 6