Low levels of hemoglobin and hematocrit reduce oxygen supply to the tissue, thus impairing the healing of pressure ulcers. Anemia is found in nearly all the patients with deep or multiple ulcers [20]. This may be caused by the low nutritional status of the patient, including low levels of protein and albumin. Iron therapy is not recommended to correct lower levels of hemoglobin or low hematocrit because the anemia could have resulted from the inability to use stored iron and not from iron deficiency [21]. In severe anemia secondary to sepsis, blood transfusion may be necessary before surgery. The author recommends that patients should have a hemoglobin level of at least 10 g/dL before surgery.

A total lymphocyte count less than 1,500 mm [3] is a risk factor predisposing in development of pressure ulcer. The cause of this low level could be non-nutritional and associated with overwhelming infection and the use of steroids that compromise the immune system of the body.

Calories are required to fuel all essential body processes and it is important, when giving a high-protein diet, to take into consideration that each gram of nitrogen needs about 150–200 kcal to be utilized by the body. Patients with pressure ulcers need more energy than other patients, especially if they have a spinal cord injury. The explanation for the increased energy expenditure is the underlying chronic inflammatory process involving cytokines and cortisol [18]. It is estimated that patients with pressure ulcers need about 30–40 kcal/kg of body weight/day [22]. Protein is essential for tissue growth and the recommended total protein requirement for patients with stage IV pressure ulcers is 1.5 g–2.0 g/kg of body weight [22].

Deficiencies in micronutrients, zinc, vitamin C, vitamin A, and vitamin E are associated with poor wound healing. However, there is no strong evidence indicating that deficiency in these supplements is a risk factor in pressure ulcer development. Zinc is known to be involved in the structure of protein, particularly collagen. It is recommended to give oral zinc sulfate in doses of 220 mg/day in the acute stage of wound healing. Vitamin C plays an important role in the hydroxylation of praline and lysine during collagen formation. Optimal wound healing may occur with vitamin C intake of 10–20 mg daily, the same as when 500 mg of vitamin C is given daily [23]. Vitamin A deficiency results in delay of wound healing, but it is not highly recommended to give it routinely because of unproven benefits and potential toxicity.

Nutritious high-calorie, high-protein daily meals will likely be recommended by the dietician. When a patient is reported as not eating well, a calorie count should be ordered for three successive days to determine the exact number of calories/protein intake per day. Based on the results, plan should be put in action to overcome dietary insufficiencies.

The medical history obtained for patients with spinal injury or neurological disease presenting with pressure ulcer should include history of spasticity and type of medication prescribed and its effectiveness. Muscle spasms are common in high-level spinal cord injury (upper motor neuron lesion). Spasms increase in intensity and duration when the patient suffers from stresses like infection or pain. Spinal cord injured patients consider spasms in the lower extremities as a form of movement to help aid the patient in transfers. The side effect of muscle spasms in these patients is that they can predispose in developing pressure ulcers when the patient cannot sit in a wheelchair or when laying in bed in an improper position. In these cases, patients have greater pressure on the skin in some areas than others, which can produce skin breakdown. Muscle spasms can act as shearing forces, for example, over the heel or medial surfaces of the knee area, where pressure ulcers can develop. Severe spasticity can cause subluxation of the hip joints and rotation of the greater trochanter posteriorly; a pressure ulcer can develop over the area, as the greater trochanter will become a pressure point in the sitting position instead of the ischial tuberosity. The effects of muscle spasms during the operation for flap surgery can make it difficult to position the patient on the operating table (Figs. 6.1a, b).

The effect of general anesthesia may sometimes help to control spasticity and allow placement of the patient in the prone position. In the postoperative period, uncontrolled muscle spasms risk flap wound dehiscence [24]. The author’s clinical observation is that the flap wound may develop serious discharge, preventing the sealing of the wound and predisposing to infection. Spasms can also prevent healing of the flap as a result of development of a seroma under the flap. This can be observed by an increase in the amount of drainage in the surgical drainage system, which indicates that some shearing is occurring between the flap and its bed secondary to spasm forces.

Medical management of spasms should begin at least 1 month before surgery. Patients should be given antispasmodic medication and followed to observe any side effects. Some common medications used in clinical practice for control of spasms are discussed below.