DECUBITUS ULCER

Management
General principles of wound assessment and treatment are as follows:

Wound care may be broadly divided into non-operative and operative

methods
For stage I and II pressure ulcers, wound care is usually conservative (ie,

nonoperative)
For stage III and IV lesions, surgical intervention (eg, flap reconstruction)
may be required, though some of these lesions must be treated

conservatively because of coexisting medical problems[1]

Approximately 70%-90% of pressure ulcers are superficial and heal by
second intention

Successful medical management of pressure ulcers relies on the following key

principles:

Reduction of pressure
Adequate debridement of necrotic and devitalized tissue
Control of infection
Meticulous wound care

If surgical reconstruction of a pressure ulcer is indicated, medical status must

be optimized before reconstruction is attempted. General measures for
optimizing medical status include the following:

Control of spasticity
Nutritional support as appropriate
Cessation of smoking
Adequate pain control
Maintenance of adequate blood volume
Correction of anemia
Maintenance of the cleanliness of the wound and surrounding intact skin
Management of urinary or fecal incontinence as appropriate
Management of bacterial contamination or infection

Additional nonsurgical treatment measures include the following:

Pressure reduction - Repositioning and use of support surfaces

Wound management - Debridement, cleansing agents, dressings, and

antimicrobials
Newer approaches still being studied - Growth factors (eg, becaplermin),
negative-pressure wound therapy, and electrotherapy

Surgical interventions that may be warranted include the following:

Surgical debridement - Always provide adequate analgesia! Necrotic tissue

must be removed for ulcer healing; surgical debridement is the fastest and
most effective method when there is healthy surrounding tissue. Note: If
the patient is close to dying, and/or the wound will never heal, then
debridement should not be attempted. Debridement gels (such as
Hypergel, Santyl, Nu-gel) are applied onto an ulcer under an occlusive
dressing (such as DuoDerm), are available for ulcers that dont require
surgery or when surgical debridement is incomplete. These products
come with or without enzymes to encourage autolytic or enzymatic
debridement. For minimally necrotic ulcers, occlusive dressings such as
DuoDerm, changed weekly, promote autolysis. A commonly prescribed
form of mechanical debridement is the use of saline, wet-dry dressings.
This treatment actually retards healing by pulling off new epithelial cells
as part of healthy granulation tissue; its use for the treatment of skin
ulcers should be abandoned.

Diversion of the urinary or fecal stream

Release of flexion contractures
Wound closure
Amputation

Options available for surgical management of pressure ulcers are as follows:

Direct closure (rarely usable for pressure ulcers being considered for

surgical treatment)
Skin grafts
Skin flaps

Myocutaneous (musculocutaneous) flaps

Free flaps

The choice of reconstruction approach depends on the location of the pressure

ulcer (eg, ischial, sacral, or trochanteric).
Prevention, if achievable, is optimal. Prevention of pressure ulcers has 2 main
components:

Identification of patients at risk

Interventions designed to reduce the risk

Treating Pressure Ulcers: Cleaning and Dressing

Its imperative that pressure ulcers be kept clean, moist, and covered. Doing so
helps reduce the risk of infection and speeds up the healing process. To
promote healing, clean pressure ulcers at each dressing change. Take care to
choose the most appropriate type of cleanser and dressing.
Caution

Do not use heat lamps or drying agents, such as alcohol. They dry out
wounds and can kill fragile new tissue.

Do not use antiseptic agents, such as povidone-iodine and hydrogen

peroxide, because they are toxic to new cells.

Be aware that if dressings become dry, they may fuse with new cells,
causing loss of new tissue when dressings are removed. Remove or change
dressings before they dry out.

Silver-based dressings are very effective for killing bacteria, and they are
safe for newly developing tissues.

Wound Irrigation
An irrigating catheter or syringe and saline may be used to flush the ulcer free
of debris. Wound cleansers may also be used to loosen up and clean out debris.
The amount of pressure used during irrigation should be enough to clean the
wound without damaging it. Follow your facilitys guidelines regarding
irrigation.
Adding Moisture
Maintaining a clean, moist wound bed is essential for promoting healing.
Certain dressings help keep ulcers moist. Be sure to fill spaces loosely with
dressings to prevent fluid and bacteria from building up. Hydrogels can also
help retain moisture.
Types of Dressings
Many kinds of dressings are available. Be sure to follow the manufacturers
instructions for the specific dressing used. If a wound doesnt respond to one
type of dressing, consider changing the treatment plan.

Moist gauze helps keep the wound moist and absorbs excess fluid. Gauze
should be dampnot wetwith saline. Too-wet gauze can weaken
surrounding tissue.

Transparent films are thin and flexible and help protect wounds from
water and bacteria.

Hydrocolloids absorb exudate, forming a nonadhesive gel. This helps

maintain a moist wound environment. Hydrocolloids also protect the wound
from water and bacteria.

Hydrogels are water-based gels and dressing sheets that keep wounds
moist. They are also soothing and can help ease pain.

Alginates are highly absorptive dressings made from seaweed. When

combined with wound exudate the dressing may form a gel that helps
maintain a moist wound bed.

Foams absorb exudate and keep the wound moist. They are used to cover
or fill wounds.

Collagens absorb exudate and help maintain a moist wound

environment. They may also promote new tissue growth.

Antimicrobials help prevent and treat infection. These dressings come in

many forms.

Negative Pressure Wound Therapy

Negative pressure wound therapy (NPWT)also called vacuum-assisted closure
removes exudate, helps reduce bacterial growth, and promotes blood flow
and granulation formation. First, a foam dressing is placed in the wound and
the wound is covered with an occlusive dressing. Then tubing is attached to a
pump, which creates subatmospheric pressure in the wound. Keep in mind
that patients may require analgesia as dressing changes can be painful.