Management of Pressure Ulcers
Management of Pressure Ulcers
The morbidity and mortality resulting from pressure sores and the economic impact on an already taxed health-care system is staggering. This article provides an overview of the management of pressure sores with particular reference to the cancer patient. It is, of course, virtually impossible to justly review such a vast subject in this manner. However, despite the inherent limitations, the author manages to present a concise, orderly overview of the management of pressure sores in the cancer patient. Although treatment algorithms can be helpful in formulating a management plan, each patient is different, and the care plan must be tailored to the individual.
The single most important factor in the management of pressure sores is prevention, and the importance of prevention cannot be overemphasized. The author points out the limitations of risk assessment tools such as the Norton and Braden scales. Prevention of pressure sores requires identifying the patient at risk, relieving the pressure, and monitoring the patient carefully.
Treatment and Prevention Options
There are a variety of preventive protocols, and each can be tailored to the individual patient. However, we agree that successful management requires a multidisciplinary approach. We have found that our wound care nurses are an invaluable part of such a team. The sine qua non of the prevention and treatment of pressure sores is pressure relief. Many foam mattresses, low-air-loss mattresses or beds, and air-fluidized beds are available to help with pressure relief, and the choice will be dictated by the needs of the patient.
Sharp surgical excision is the debridement method of choice for stage III/IV ulcers. Although numerous new enzymatic debridement agents are available, these agents should be considered an adjunct to surgical debridement. Infected pressure sores require adequate debridement of nonviable tissue and drainage of any collected fluid. We agree with the author that most infected pressure sores are polymicrobial, requiring treatment with broad-spectrum antibiotics. To direct antibiotic therapy, we prefer to send tissue for culture rather than relying on swabs of the wound.
The author points out the difficulty of diagnosing osteomyelitis. Our preferred approach is to perform a bone biopsy. Exposed bone at the base of a pressure sore can be debrided and sent for histology and culture. If bone is not exposed, it is preferable to biopsy the bone through the adjacent intact skin and not through the ulcer itself to avoid inoculation of the bone.
We have found the vacuum-assisted closure (VAC) device to be effective in the management of large stage III/IV ulcers, particularly in patients who are not candidates for flap coverage. Vacuum-assisted closure should not be used until the ulcer is free of nonviable tissue and infection. Although some do not recommend use of VAC in the presence of exposed bone, we have had success healing ulcers even with exposed bone. The VAC is usually changed three times per week and decreases the nursing burden and degree of patient discomfort associated with frequent dressing changes.
The decision as to whether a patient is a candidate for surgical closure involves the consideration of multiple factors. The debilitated patient with numerous medical problems is not a good candidate for surgery. Surgical closure of a pressure sore includes complete excision of the ulcer, pseudo bursa, ostectomy, and flap coverage.
Generally speaking, skin grafts are not a good choice for coverage of a pressure sore. Most pressure sores should be covered with a flap to provide well-vascularized tissue and adequate padding over the bony prominence. The choice of flap will be determined largely by the location of the pressure sore.
We congratulate the author for appropriately emphasizing the importance of the prevention and management of pressure sores in the cancer patient.