11 Pressure Ulcers

Noah H. Prince, Rachel Cohen-Shohet and Bruce A. Mast

Abstract

Pressure ulcers are a major concern in patient care. Left untreated, pressure ulcers can turn into pressure wounds that not only prolong healing, but additionally threaten the health and well being of the patient. Because of this, it is imperative that ulcers be promptly and properly treated. The authors take the reader through presurgical preparation and the operative interventions of debridement and reconstruction (often, flap reconstruction), to the postoperative care treatments that promote a good outcome.

Norton scale – Braden scale – National Pressure Ulcer Advisory Panel Staging System – debridement – reconstruction – vacuum-assisted closure (VAC)

11 Pressure Ulcers

11.1 Goals and Objectives

Understand the risk factors for pressure ulcers and be able to describe how they contribute to the formation of pressure wounds.
Appreciate the multimodality approach for treatment and prevention of pressure ulcers.
Be able to assess patients and optimize ancillary treatments prior to surgical intervention.
Know surgical treatment options in the setting of sacral, ischial, and trochanteric pressure ulcers.
Be able to counsel patients on postoperative treatment goals and outcomes of intervention.

**Fig. 11.1** Sacral, ischial, and trochanteric pressure wounds are frequently seen over bony prominences in bedridden patients over bony prominences.

**Fig. 11.2** A lack of pressure relief techniques and devices place the heels at risk in bedridden and supine patients.

11.2 Patient Presentation

A growing number of patients are presenting with pressure ulcers. Studies from Europe calculate the incidence in hospitalized patients to be 3% to more than 30%. ¹ The cost of pressure ulcer treatment is estimated to be 11 billion dollars per year in the United States and utilizes 4% of the National Health Service’s budget in the United Kingdom annually (1.4–2.1 billion U.S. dollars). ²

Pressure ulcers occur in patients with impaired mobility in association with multiple risk factors. A lack of pressure relief techniques and devices places areas over bony prominences at risk (Fig. 11‑1, Fig. 11‑2, Fig. 11‑3, Fig. 11‑4) ² : A lack of pressure relief techniques and devices place the heels at risk in bedridden and supine patients (Fig. 11‑3; Fig. 11‑4).

**Fig. 11.3** Heel ulceration can result, as seen in this patient with calcaneal erosion.

**Fig. 11.4** **(a)** Isolated pressure relief of the heel. **(b)** Heel protection provided by gel pad.

More worrisome is the resulting cone-shaped distribution of injury, with deeper tissues closest to the bone suffering the greatest damage. In these wounds, small-appearing superficial ulcers can have more severe injuries deep to the surface with an area of soft-tissue necrosis much greater than skin necrosis. ³ ^, ⁴ ^, ⁵

Although excess or localized pressure remains the center of this problem, other contributing factors should not be ignored. These include shearing forces, which may worsen superficial damage, moisture (usually from bladder or bowel incontinence), which may hasten skin breakdown, and friction (usually from patient transfers), which may tear skin. Other factors that contribute to poor wound healing similarly affect pressure ulcers. Considerations such as poor nutrition, underlying infection, chronic edema, and peripheral vasculature disease can increase the time or resources necessary for wound healing. ⁶ ^, ⁷

Several recent studies have outlined risk factors such as elderly age, male gender, long-term admission, history of ulcers, diabetes, and falls. Bedbound status, poor nutrition, and a prior stroke also contribute in addition to lymphopenia, dry sacral skin, low weight, high illness severity scores, and residents of nursing homes. In these patients, it is crucial to balance prevention efforts with the level of risk. ⁸ ^, ⁹ ^, ¹⁰ ^, ¹¹ ^, ¹² ^, ¹³

Both the Norton scale and Braden scale can be used with 70 to 90% sensitivity to identify those patients at risk for pressure ulcer formation ¹⁴ ^, ¹⁵ The Norton scale uses mental and physical condition, activity level, mobility, and incontinence factors in its formula, while the Braden scale focuses on sensory perception, moisture level, activity, mobility, nutritional status, friction, and shear force. ¹⁵ ^, ¹⁶ However, evidence supports that good clinical judgment can be equally as effective as a risk predictor. ¹⁷ ^, ¹⁸

The diagnosis of pressure ulcers is largely clinical, with early recognition of pressure ulcers allowing for early treatment. Grading of pressure ulcers follows the National Pressure Ulcer Advisory Panel Staging System. The original staging system developed by Shea in 1975 was revised in 2007 by the National Pressure Ulcer Advisory Panel. The panel stages pressure ulcers by six categories: stages I, II, III, IV, unstageable, and suspected deep tissue injury as described in Table 11‑1. ¹⁹

**Table 11.1** Staging of pressure wounds by National Pressure Ulcer Advisory Panel guidelines
Stage I	Nonblanchable erythema. The skin over bony prominences may appear different from surrounding skin: painful, warm, cool, soft, or firm
Stage II	Partial-thickness loss of dermis, presenting as an ulcer with a shallow wound bed. Likewise it may appear as a blister, either opened or closed
Stage III	Full-thickness skin loss. The depth of the wound may vary with anatomic location, but there is full loss of dermis. In some cases, subcutaneous fat may be visible. Bone, tendon, or muscle are not be visible
Stage IV	Full-thickness loss with exposed tendon, muscle, and/or bone. Due to exposed structures, the risk for osteomyelitis is higher in stage IV ulcers
Unstageable/unclassified	Full-thickness skin or tissue loss in which the actual or true depth of the ulcer is unknown due to slough or eschar. In order to stage the wound properly, slough or eschar must be removed
Suspected deep tissue injury	Discolored area—usually purple or maroon, which is defined by either discolored intact skin or blood-filled blister from pressure or shearing forces. These wounds may evolve into a true pressure ulcer
Source: . Adapted from Black J, Baharestani MM, Cuddigan J, et al; National Pressure Ulcer Advisory Panel. National Pressure Ulcer Advisory Panel’s updated pressure ulcer staging system. Adv Skin Wound Care 2007;20(5):269–274

Lastly, many patients will present with acute or chronic soft-tissue infection, colonization, or underlying osteomyelitis. In these patients, infection control is paramount to reconstructive interventions.

11.3 Preparation for Surgery

Prior to surgical intervention, it is essential to have an in-depth discussion with the patient regarding postoperative expectations and outcomes. Traditionally, flaps for pressure wounds necessitate prolonged bed-bound status, maintenance of nutritional intake, and other aspects of wound care which may require significant patient cooperation. Given the limited number of wound coverage options, it is imperative to optimize chances for flap success. This frequently requires a fully informed and well-prepared patient prior to surgical intervention.

Before reconstruction can take place, the site must be free of infectious nidus. This typically involves soft-tissue debridement with potential extension to bone. Flap viability is severely compromised in the setting of high bacterial growth. ²⁰ In that respect, deep wound cultures should be taken to tailor antibiotic therapy. In the setting of suspected osteomyelitis, magnetic resonance imaging (MRI) and bone biopsy may be used for diagnosis and further tailoring of a prolonged antibiotic course. If underlying osteomyelitis is not treated, flap failure may result.

In addition to control of local infection, optimization of nutrition is crucial to promote normal wound healing. Adequate sources of protein (1.5–3g/kg/day) and nonprotein calories (25–35 cal/kg/day), as well as vitamins and minerals, should be obtained. ²¹ Nutritional markers such as albumin and prealbumin may be warranted to trend progress, which should be balanced with timing of optimal wound reconstruction.

Diabetes plays an important role in wound healing; hemoglobin A1c greater than 6 has been associated with wound dehiscence and recurrence. ²² Additional factors such as smoking cessation and cardiac risk mitigation should also be discussed with the patient.

Preoperative planning for moisture control should also be considered. Fecal incontinence introduces high moisture, bacterial load, and shearing forces during routine cleaning. While this can sometimes be controlled with local hygiene, fecal diversion via colostomy may be necessary. If urinary incontinence is an issue, then bladder catheterization may be indicated as well.

Generally, it is believed that enzymatic debridement with the use of products such as collagenase, papain, or urea can be used for devitalized tissue in stage I and II pressure ulcers. Many chemical solutions have been used including Dakin’s solution, hydrogen peroxide, and iodine to assist with mechanical debridement of devitalized tissue, but should otherwise be used with caution. ²⁰ These agents are effective in controlling bacterial load, but also may be detrimental to human cells needed for healing. Mechanical and surgical debridement is generally recommended for decubitus ulcers stage III or higher.

Despite all operative and ancillary care, surgical reconstruction is of little benefit without plans for future prevention, most importantly pressure relief. In the immediate postoperative period, flap healing is compromised in the setting of ischemic tissue promoted by high pressures; so, plans for support services, mattresses, and cushions must be arranged preoperatively (Fig. 11‑5; Fig. 11‑6; Fig. 11‑7).

**Fig. 11.5** (**a, b**) Pressure-relieving chair cushions are an important part of prevention and treatment of pressure wounds.

**Fig. 11.6** Cushioned mattresses may be helpful to minimize pressure over bony prominences.

**Fig. 11.7** Bedridden patients may benefit from air-fluidized or low air loss beds which more evenly distribute weight and pressure.

Furthermore, without sufficient health literacy and social support, many patients are unable to continue to provide themselves with these environments, resulting in development of new pressure wounds. In that sense, coordinated efforts should be made to provide continued assessment, education, and care for these patients.

11.4 Treatment

11.4.1 Indications for Surgical Intervention

The decision to proceed with surgical intervention for pressure ulcers varies with the specific circumstances of the patient and the surgical team involved. It is important that the patient be optimized from a medical standpoint, as discussed previously. Control of infection with appropriate antibiotics and tissue debridement and optimization of nutrition are necessary. ²³ ^, ²⁴ ^. Generally, a serum prealbumin of greater than 15 mg/dL is considered within the normal range and would represent suitability for surgical intervention. Likewise, factors that created the pressure ulcer should be resolved: ischial pressure ulcers are often formed in the seated position, being caused commonly in the wheelchair bound patient. Patients can often identify a change in brand of cushion, wheelchair, or device that caused the formation of the ulcer. It is important to correct these factors as to not cause breakdown postoperatively. Lastly, social hurdles that may prevent the patient from succeeding in flap surgery must be identified. Lack of resources for special equipment including beds and wheelchairs, as well as lack of social support for long-term care, can hinder the patient’s recovery and overall success postoperatively. ²⁰ Due to the magnitude of the surgery, the resources required, and the high risk of recurrence, a patient should have been medically optimized and have failed all conservative nonsurgical treatments prior to proceeding into surgical reconstruction. In addition, they should understand the long-term recovery associated with flap reconstruction, need for life-long compliance, and have resources in place prior to proceeding with reconstructive or flap surgery.

11.4.2 Operative Interventions

Surgical intervention can be largely divided into debridement and reconstruction. In most cases, both are required for a successful outcome.

11.5 Debridement

Operative debridement of pressure sores has several key goals. First and foremost begins with removal of necrotic, dead areas as well as chronic scar. This will enable better wound care, including use of enzymatic debridement application, as well as placement of vacuum-assisted closure (VAC) therapy. Second, debridement should remove or control soft tissue and bony infection. Removal of all infected tissues improves chances of success by minimizing bacterial load and biofilms within the wound bed, as these will both impede wound healing and potentiate failure of flap reconstruction. It is recommended that tissue be sent for pathology and culture as to help narrow antibiotic choice postoperatively. Removal of necrotic bone reduces bacterial burden, while also eliminating the bony prominence that was the causative pressure point. Debridement should be performed until healthy bleeding tissue is present in the wound bed. Likewise means of controlling the significant bleeding which is present in chronic wounds, such as sutures and electrocautery, should be readily available. Debridement of small pressure sores is possible at bedside in insensate tissue. However, debridement should ideally be performed in the operating room for large wounds with extensive tissue necrosis, tunneling, and tracking.

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