Management of Pressure Ulcers

November 1, 2001

Pressure ulcers are a common problem, with about 1.5 to 3 million individuals in the United Stated affected. Treatment may be costly, requiring lengthy periods of hospitalization. Central to the development of pressure

The morbidity and mortality resulting frompressure sores and the economic impact on an already taxed health-care system isstaggering. This article provides an overview of the management of pressuresores 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 aconcise, orderly overview of the management of pressure sores in the cancerpatient. Although treatment algorithms can be helpful in formulating amanagement plan, each patient is different, and the care plan must be tailoredto the individual.

The single most important factor in the management of pressuresores is prevention, and the importance of prevention cannot be overemphasized.The author points out the limitations of risk assessment tools such as theNorton and Braden scales. Prevention of pressure sores requires identifying thepatient at risk, relieving the pressure, and monitoring the patient carefully.

Treatment and Prevention Options

There are a variety of preventive protocols, and each can betailored to the individual patient. However, we agree that successful managementrequires a multidisciplinary approach. We have found that our wound care nursesare an invaluable part of such a team. The sine qua non of the prevention andtreatment of pressure sores is pressure relief. Many foam mattresses, low-air-lossmattresses or beds, and air-fluidized beds are available to help with pressurerelief, and the choice will be dictated by the needs of the patient.

Sharp surgical excision is the debridement method of choice forstage III/IV ulcers. Although numerous new enzymatic debridement agents areavailable, these agents should be considered an adjunct to surgical debridement.Infected pressure sores require adequate debridement of nonviable tissue anddrainage of any collected fluid. We agree with the author that most infectedpressure sores are polymicrobial, requiring treatment with broad-spectrumantibiotics. To direct antibiotic therapy, we prefer to send tissue for culturerather 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 ofa pressure sore can be debrided and sent for histology and culture. If bone isnot exposed, it is preferable to biopsy the bone through the adjacent intactskin and not through the ulcer itself to avoid inoculation of the bone.

Vacuum-Assisted Closure

We have found the vacuum-assisted closure (VAC) device to beeffective in the management of large stage III/IV ulcers, particularly inpatients who are not candidates for flap coverage. Vacuum-assisted closureshould 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, wehave had success healing ulcers even with exposed bone. The VAC is usuallychanged three times per week and decreases the nursing burden and degree ofpatient discomfort associated with frequent dressing changes.

Summary

The decision as to whether a patient is a candidate for surgicalclosure involves the consideration of multiple factors. The debilitated patientwith numerous medical problems is not a good candidate for surgery. Surgicalclosure of a pressure sore includes complete excision of the ulcer, pseudobursa, ostectomy, and flap coverage.

Generally speaking, skin grafts are not a good choice forcoverage of a pressure sore. Most pressure sores should be covered with a flapto provide well-vascularized tissue and adequate padding over the bonyprominence. The choice of flap will be determined largely by the location of thepressure sore.

We congratulate the author for appropriately emphasizing theimportance of the prevention and management of pressure sores in the cancerpatient.