Dr. Walker has provided a comprehensive
overview of the problem of pressure ulcers, with appropriate adaptation to
cancer patients. Cancer patients are frequently at high risk of developing
pressure ulcers, especially late in the disease process; yet, this topic is
As Dr. Walker has noted, the best way to manage pressure ulcers
is to prevent them, and the keys to prevention are prompt identification of
patients at risk and immediate and consistent implementation of preventive
measures. Patients who remain ambulatory are generally at low risk and do not
require risk assessment; most clinicians suggest, however, that any patient who
is chair- or bedbound undergo routine risk assessment. Use of a structured
risk-assessment tool (eg, the Braden scale) permits accurate identification of
high-risk patients and timely implementation of a prevention program.
The most important preventive strategies, as Dr. Walker states,
are routine repositioning and appropriate use of support surfaces. The many
support surfaces available can be grouped into two major therapeutic
"groups." The least expensive products are mattress overlays and
static pressure-reducing mattresses. These products are generally appropriate
for patients who can assist with turning and who have at least two intact
turning surfaces. The second group of products comprises rental mattresses or
beds. These usually feature dynamic air support with low-shear and low-friction
surfaces. They are indicated for patients who are immobile, have breakdown of
more than one turning surface, or experience pain with turning.
Routine repositioning is the keystone of any effective pressure
ulcer prevention program. When turning causes pain, beneficial strategies
include the use of turn sheets and a 30° "tilt" from supine, as
opposed to a full turn. (As Dr. Walker points out, a 30° tilt also avoids
positioning directly onto the trochanters.) Repositioning should include
elevation of the heels (with commercial products or pillows) when the patient is
supine, because the heels are a particularly vulnerable area.
Dr. Walker’s comments regarding doughnut-type devices are of
particular importance. Although these devices "appear" to relieve
pressure, they actually compromise arterial inflow and venous drainage of the
affected area and are always contraindicated. Moreover, his comments regarding
massage are equally appropriate and represent an important component of
education for the lay caregiver, who has probably heard about the
"beneficial effects" of massage.
Staging and Treatment
Dr. Walker has accurately identified some of the problems
associated with the current staging system. Although tremendous emphasis is
frequently placed on ulcer stage, the parameters that reflect progress in
healing and that direct topical therapy include wound dimensions and depth,
extent of undermining or sinus tract formation, status of the wound bed
(granulating vs necrotic), and signs of infection. These are the assessment
parameters that should be emphasized.
In regard to treatment, the author appropriately focuses
initially on correction of the causative factors. (Many clinicians begin with a
focus on topical therapy.) I would also suggest making a conscious decision,
whenever an ulcer is identified, as to the goals of treatment. As Dr. Walker
correctly points out in his conclusion, healing may be impossible due to the
patient’s general status, or the care required to promote healing may conflict
with comfort goals. In general, wounds are very unlikely to heal if the
underlying cause cannot be eliminated (eg, if the patient cannot be effectively
positioned off the area) or if the patient is nutritionally compromised (ie, in
a catabolic state as opposed to an anabolic state). In these situations, it is
best to clearly identify the goals of care as being maintenance of patient
comfort and prevention of wound deterioration.
If the goal is wound healing and/or the wound is infected,
debridement of necrotic tissue is the first step in topical care. We lack
definitive data on the best methods of debridement, or the usual time frames for
enzymatic and autolytic debridement. Wet-to-dry dressings are still the
"default dressing" in many institutions; however, this approach is
generally considered suboptimal due to the nonselective nature of the
debridement and the pain caused by dressing removal. In considering autolytic
debridement, it is helpful to consider the patient’s white blood cell count;
white blood cells play a significant role in autolytic debridement, and most
clinicians report poor response to autolysis in leukopenic patients.
Preventing Wound Infection
Prevention and management of wound infection is a major concern
when dealing with a cancer patient. As the author states, cultures are not
routinely indicated; however, most clinicians recommend cultures when clinical
infection is suspected, in order to ensure accurate identification of the
organism and treatment. Culture technique remains controversial. The Centers for
Disease Control (CDC) recommends aspiration, and the Agency for Health Care
Policy and Research (AHCPR) guidelines recommend tissue biopsyboth of these
approaches involve invasive and potentially painful procedures. In situations
where swab cultures are preferred due to simplicity and cost issues, studies
indicate that the following technique provides optimal results: Flush the wound
with sterile saline, and swab a 1-cm2 area of viable tissue with enough force to
Infection involving the surrounding tissue requires systemic
antibiotic therapy. Infections limited to the surface of the wound may be
treated with topical agents. Recent studies have shown silver-impregnated
dressings and cadexomer iodine products to be effective in reducing bacterial
counts and infectious complications. These products may prevent infections from
recurring in susceptible patients.[3,4]
Although it is true that the AHCPR guidelines and some studies
suggest that antiseptics such as sodium hypochlorite (Dakin’s solution) and
povidone iodine solution should never be used on open wounds, this remains
controversial, because other studies (and many clinicians) support the use of
these products for wounds with large amounts of necrotic tissue and/or clinical
infection.[5,6] All clinicians agree that these agents should be discontinued
when the wound bed is clean.
Dr. Walker states that the key principles of topical therapy are
to maintain a moist wound bed and to prevent maceration of the surrounding skin.
I would add to this list the importance of lightly filling dead space,
effectively managing wound exudate, and protecting the wound from trauma and
secondary infection. Dressing selection is based on wound depth (or the presence
of dead space) and the volume of exudate. Exudative wounds with depth or dead
space require an absorptive filler (eg, alginate rope) in addition to a cover
dressing, whereas deep "dry" wounds require a hydrating filler such as
a hydrogel (in addition to a cover dressing). Very shallow wounds require only a
cover dressing. The specific dressing is selected based on the volume of exudate
and the dressing’s absorptive capacity.
Finally, as Dr. Walker notes, there are a number of adjunctive
therapies now available. These therapies are designed to have an impact on the
wound healing process and are more costly than standard wound care products.
They are, therefore, most appropriately used when the goal is wound healing and
the wound fails to respond to standard therapy. They would be inappropriate for
a "maintenance" situation.
In summary, Dr. Walker has done an excellent job of addressing
the pressure ulcer problem in the cancer patient population.
1. Ramundo J, Wells J: Wound debridement, in Bryant R (ed):
Acute and Chronic Wounds: Nursing Management, 2nd ed, pp 157-177. St. Louis,
2. Stotts N: Determination of bacterial burden in wounds. Adv
Wound Care 8(4):24-46, 1995.
3. Sundberg J, Meller R: A retrospective review of the use of
cadexomer iodine in the treatment of chronic wounds. Wounds 9(3):68-86, 1997.
4. Wright J, Lam K, Burrell R: Wound management in an era of
increasing bacterial antibiotic resistance: A role for topical silver treatment.
Am J Infect Control 26:572-577, 1998.
5. Heggers J, Sazy J, Stenberg B, et al: Bactericidal and
wound-healing properties of sodium hypochlorite solutions: The 1991 Lindberg
award. J Burn Care Rehab 12(5):420-424, 1991.
6. Rodeheaver G, Mayer D: Conflicting points of view regarding
the use of povidone-iodine. Ostomy/Wound Manage 40(8):6-8, 1994.