What are the recommended management strategies for pressure ulcers?

Pressure Ulcer Management

Core Management Strategy

Use hydrocolloid or foam dressings for wound care, provide protein supplementation for patients with nutritional deficiencies, implement systematic repositioning every 2-4 hours, and place patients on advanced static air mattresses rather than alternating-air systems. 1, 2

Wound Dressing Selection

• Apply hydrocolloid dressings as first-line treatment because they are superior to gauze dressings for reducing wound size and equivalent to foam dressings for complete wound healing. 1
• Foam dressings (hydrocellular or polyurethane) are an acceptable alternative with similar efficacy to hydrocolloid dressings. 1
• Avoid gauze dressings as they are inferior to modern moisture-retentive dressings. 1
• Avoid dextranomer paste as it is inferior to other dressings for reducing wound size. 1
• Clean wounds with normal saline or water to remove debris, avoiding harsh antiseptics that damage healing tissue. 3

Nutritional Supplementation

• Provide protein or amino acid supplementation to all patients with pressure ulcers and nutritional deficiencies to reduce wound size and accelerate healing. 1, 2
• This recommendation applies specifically to patients with documented nutritional deficiencies, as the evidence may not generalize to well-nourished patients. 1
• Do not use vitamin C supplementation alone, as evidence shows no benefit over placebo. 1, 4

Support Surface Selection

• Place all patients with existing pressure ulcers on advanced static air mattresses or advanced static overlays immediately. 1, 2, 5
• Air-fluidized beds are superior to standard hospital beds for reducing pressure ulcer size when advanced static surfaces are insufficient. 1
• Avoid alternating-air mattresses and low-air-loss mattresses because they provide no clear benefit over static surfaces, cost significantly more, and add unnecessary noise and disruption. 1, 5, 4

Repositioning Protocol

• Implement systematic repositioning every 2-4 hours around the clock for all patients with pressure ulcers, with pressure zone checks at each turn. 2
• Use 2-hour intervals for hemodynamically stable patients on standard surfaces. 2
• When using advanced pressure-reducing mattresses, repositioning intervals can be extended to 4 hours without increased ulcer incidence. 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, 4
• Avoid the flat supine position entirely as it concentrates pressure on vulnerable areas. 2
• Elevate the upper body ≥40 degrees in patients who can tolerate this position. 2

Critical caveat: Despite widespread use, no randomized trials demonstrate that repositioning improves healing rates of existing ulcers, though it remains standard practice for prevention. 6

Debridement Indications

• Perform urgent sharp debridement immediately if advancing cellulitis or sepsis occurs. 3
• Use mechanical, enzymatic, or autolytic debridement methods for non-urgent situations when necrotic tissue is present. 3
• In hospice or palliative care patients, avoid aggressive sharp debridement unless advancing cellulitis or sepsis requires urgent intervention, as pain and trauma may outweigh benefits. 4

Infection Management

• Manage bacterial load with wound cleansing using normal saline. 3
• Consider topical antibiotics if there is no improvement in healing after 14 days of appropriate wound care. 3
• Reserve systemic antibiotics for advancing cellulitis, osteomyelitis, or systemic infection (fever, hypotension, altered mental status). 4, 3
• These infections are typically polymicrobial, requiring coverage of Gram-positive, Gram-negative, and anaerobic organisms. 4

Adjunctive Therapies

• Use electrical stimulation as adjunctive therapy to accelerate wound healing in stage 2-4 ulcers, though evidence for complete wound healing is insufficient. 1
• Monitor frail elderly patients closely for skin irritation and adverse events with electrical stimulation. 1
• Light therapy may reduce ulcer size but shows no benefit over sham treatment for complete wound healing. 1
• Avoid electromagnetic therapy, negative-pressure wound therapy, therapeutic ultrasound, and laser therapy as they show no benefit over controls. 1

Biological Agents

• Consider platelet-derived growth factor for more severe ulcers, as it improves healing compared with placebo. 1
• Evidence is insufficient for other biological agents including fibroblast, nerve, and macrophage suspensions. 1

Daily Skin Assessment

• Conduct thorough visual and tactile skin checks of all at-risk areas at least once daily, with particular attention to sacrum, heels, ischium, and occiput. 2
• Use validated risk assessment tools such as the Braden Scale upon admission and reassess regularly based on clinical condition changes. 2
• Document each position change with time and skin assessment findings to ensure adherence. 2

Skin Care 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

Early Mobilization

• Begin mobilization as soon as the patient is medically stable. 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

Surgical Considerations

• Consider surgery for advanced-stage pressure ulcers when conservative management fails. 1
• Evidence is insufficient to determine superiority of one surgical technique over another for wound closure. 1
• Dehiscence is more common when bone is removed and in patients with ischial ulcers. 1

Implementation Framework

• Establish a multicomponent prevention and treatment program including standardization of interventions and documentation, multidisciplinary team involvement, ongoing staff education, sustained audit and feedback, and regular all-facility meetings. 2, 5
• Designate "skin champions" to educate personnel on preventive and treatment care. 2, 5
• This bundled approach demonstrates cost savings of approximately $11.5 million annually in hospital systems while significantly reducing pressure ulcer prevalence. 2, 5