What is the best management for pressure ulcers (bed sores)?

Best Management for Pressure Ulcers (Bed Sores)

Use hydrocolloid or foam dressings for wound care, provide protein or amino acid supplementation, reposition patients every 2-4 hours, and place patients on advanced static air mattresses or reactive air surfaces rather than standard foam surfaces. 1, 2

Wound Dressing Selection

• Apply hydrocolloid dressings as first-line treatment—they are superior to gauze dressings for reducing wound size and equivalent to foam dressings for complete healing. 1, 3, 4
• Foam dressings are an acceptable alternative with similar efficacy to hydrocolloid dressings. 1, 2
• Avoid dextranomer paste as it is inferior to other dressings for reducing wound size. 1, 3
• Do not use antimicrobial dressings solely to accelerate healing. 4
• Common adverse effects include skin irritation, inflammation, tissue damage, and maceration—monitor for these at each dressing change. 1, 4

Nutritional Support

• Provide protein or amino acid supplementation to all patients with pressure ulcers, particularly those with nutritional deficiencies—this reduces wound size and accelerates healing. 1, 3, 2
• Do not use vitamin C supplementation alone as it shows no benefit over placebo. 1, 3, 4
• The optimal dose or form of protein has not been established, but supplementation should be initiated alongside standard wound care. 1

Support Surface Selection

• Place patients on reactive air surfaces (static air overlays) or advanced static air mattresses—these reduce pressure ulcer incidence by approximately 54% compared to foam surfaces. 1, 2, 5
• Alternating pressure (active) air surfaces reduce pressure ulcer risk by 37% compared to foam and are more cost-effective for prevention. 1, 5
• Air-fluidized beds are superior to standard hospital beds for large pressure ulcers (≥7.8 cm²), showing median decrease in surface area of -5.3 cm² versus +4.0 cm² increase with conventional therapy. 6
• Reactive gel surfaces may reduce pressure ulcer incidence, particularly in operating rooms and long-term care settings. 1, 5

Repositioning Protocol

• Reposition patients systematically every 2-4 hours with pressure zone checks at each turn. 2, 7
• Keep the head of the bed at the lowest safe elevation to prevent shear forces. 7

Debridement and Wound Preparation

• Perform sharp debridement of necrotic tissue and callus when not contraindicated. 4, 7
• Urgent sharp debridement is required if advancing cellulitis or sepsis occurs. 7
• For non-urgent cases, mechanical, enzymatic, or autolytic debridement methods are acceptable alternatives. 7
• After debridement, cleanse wounds preferably with normal saline before applying dressings. 7

Stage-Specific Treatment Algorithm

Stage I-II Ulcers:

• Apply hydrocolloid or foam dressings as primary treatment. 3, 4
• Initiate protein or amino acid supplementation. 3, 4
• Place on reactive air surfaces or advanced static mattresses. 2, 5

Stage III-IV Ulcers:

• Debride necrotic tissue first. 3, 4, 7
• Apply hydrocolloid or foam dressings after debridement. 3, 4
• Consider platelet-derived growth factor for severe ulcers—it improves healing compared to placebo. 1, 3, 4
• Consider air-fluidized beds for large ulcers. 6

Adjunctive Therapies

• Use electrical stimulation as adjunctive therapy to accelerate wound healing in Stage 2-4 ulcers, though it does not improve complete wound closure rates. 1, 3
• The most common adverse effect is skin irritation; frail elderly patients are more susceptible to adverse events. 1, 3
• Light therapy may reduce ulcer size without substantial adverse events, but evidence for complete healing is insufficient. 1
• Do not use electromagnetic therapy, negative-pressure wound therapy, therapeutic ultrasound, or laser therapy as they show no benefit over controls. 1

Infection Management

• Manage bacterial load with wound cleansing. 7
• Consider topical antibiotics only if there is no improvement in healing after 14 days. 7
• Reserve systemic antibiotics for advancing cellulitis, osteomyelitis, or systemic infection. 2, 7

Surgical Considerations

• Surgery is an option for advanced-stage pressure ulcers when conservative management fails. 1, 2
• Dehiscence is the most common complication, occurring more frequently when bone is removed and in patients with ischial ulcers (versus sacral or trochanteric). 1, 3
• Reoperation rates due to recurrence or flap failure range from 12% to 24%. 1
• Patients with spinal cord injury have higher recurrence rates after surgical closure. 3

Cost-Effectiveness Considerations

• Alternating pressure air surfaces are more cost-effective than foam surfaces for prevention. 1, 5
• Reactive air surfaces may cost an extra 26 US dollars per ulcer-free day in the first year compared to foam surfaces in long-term care settings. 5, 8

Critical Pitfalls to Avoid

• Do not rely on gauze dressings—they are inferior to hydrocolloid dressings for wound size reduction. 1, 3
• Do not use alternating-air beds or low-air-loss mattresses as first-line support surfaces—they do not differ substantially from other surfaces for reducing wound size. 1
• Do not assume wound size reduction equates to complete healing—the relationship between these outcomes is not well-defined. 1, 3
• Do not apply electrical stimulation to frail elderly patients without careful monitoring for adverse events. 1, 3